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OPTUM PHARMACY 702, LLC
RRC340021-00 ATRIUM HEALTH CLEVELAND
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Covered Entity Details
Entity Name
ATRIUM HEALTH CLEVELAND
Subdivision Name
Type
Rural Referral Center
340B ID
RRC340021-00
Entity Address
201 EAST GROVER STREET
SHELBY, NC 28150
Medicare Provider Number
340021
Participating Start Date
7/1/2021
Last Recertification Date
9/9/2021
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/19/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/18/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Don McCoy Mabe, VP, Pharmacy
(704) 512-7623
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
5/19/2021
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