Contract Pharmacy Details

OPTUM PHARMACY 701, LLC
DSH110034 AU Medical Center, Inc.

Covered Entity Details

Entity Name

AU Medical Center, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH110034

Entity Address

1120 15TH ST.
AUGUSTA, GA 30912

Medicare Provider Number

110034

Participating Start Date

12/1/1992

Last Recertification Date

8/22/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 701, LLC

Pharmacy Address

8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029

Pharmacy Comments

Contract Details

Approval Date

4/15/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Allen R Butcher, CFO
(706) 721-3929

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

4/15/2021

340B Drug Pricing Program Database