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OPTUM PHARMACY 702, LLC
RRC070024-00 THE WILLIAM W. BACKUS HOSPITAL
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Covered Entity Details
Entity Name
THE WILLIAM W. BACKUS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC070024-00
Entity Address
326 WASHINGTON STREET
NORWICH, CT 06360
Medicare Provider Number
070024
Participating Start Date
4/1/2025
Last Recertification Date
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/16/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/13/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Anthony Mastroianni, Regional Vice President, Finance
(860) 889-8331 Ext: 2311
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/16/2021
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