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OPTUM PHARMACY 706, INC.
DSH390086 DUBOIS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
DUBOIS REGIONAL MEDICAL CENTER
Subdivision Name
dba Penn Highlands DuBois
Type
Disproportionate Share Hospital
340B ID
DSH390086
Entity Address
100 HOSPITAL AVENUE
DUBOIS, PA 15801
Medicare Provider Number
390086
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
7/12/2021
Contract Begin Date
7/16/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Kline, CFO
(814) 375-6377
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/12/2021
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