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OPTUM PHARMACY 705, LLC
PED453302-00 CHILDREN'S MEDICAL CENTER DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
Type
Children's Hospital
340B ID
PED453302-00
Entity Address
1935 MEDICAL DISTRICT DRIVE
DALLAS, TX 75235
Medicare Provider Number
453302
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/8/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeremiah Radandt, President Corporate Services & CFO
(214) 456-2522
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
7/8/2021
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