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OPTUM PHARMACY 702, LLC
CAH301310-00 ANDROSCOGGIN VALLEY HOSPITAL , Inc.
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Covered Entity Details
Entity Name
ANDROSCOGGIN VALLEY HOSPITAL , Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH301310-00
Entity Address
59 PAGE HILL ROAD
BERLIN, NH 03570-3542
Medicare Provider Number
301310
Participating Start Date
9/29/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/1/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Suzanne Landry, Vice President
(603) 326-5608
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/1/2021
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