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OPTUM PHARMACY 702, LLC
RRC330191-00 GLENS FALLS HOSPITAL
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Covered Entity Details
Entity Name
GLENS FALLS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330191-00
Entity Address
100 PARK ST
GLENS FALLS, NY 12801
Medicare Provider Number
330191
Participating Start Date
8/18/2020
Last Recertification Date
9/15/2021
Entity Termination Date
10/1/2022
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
8/3/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Paul J Scimeca, Senior Vice President/Chief Operating Officer
(518) 926-5902
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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