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OPTUM PHARMACY 702, LLC
DSH470005 RUTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
RUTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470005
Entity Address
160 ALLEN STREET
RUTLAND, VT 05701
Medicare Provider Number
470005
Participating Start Date
7/1/2016
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Judi K Fox, CFO
(802) 747-1632
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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