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OPTUM INFUSION SERVICES 500, INC
CAH451356-00 MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451356-00
Entity Address
815 N VIRGINIA STREET
PORT LAVACA, TX 77979
Medicare Provider Number
451356
Participating Start Date
9/16/2010
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 500, INC
Pharmacy Address
5627 UNIVERSITY HTS STE 105
SAN ANTONIO, TX 78249-3583
Pharmacy Comments
Contract Details
Approval Date
7/14/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON ANGLIN, CEO
(361) 552-6713 Ext: 240
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/14/2021
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