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OPTUM PHARMACY 702, LLC
RRC330094-00 Columbia Memorial Hospital
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Covered Entity Details
Entity Name
Columbia Memorial Hospital
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330094-00
Entity Address
71 Prospect Aveune
Hudson, NY 12534
Medicare Provider Number
330094
Participating Start Date
10/1/2013
Last Recertification Date
9/6/2024
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
8/4/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bryan T. Mahoney, Chief Financial Officer
(518) 697-3230
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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