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OPTUM PHARMACY 700, LLC
DSH490053 JOHNSTON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHNSTON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490053
Entity Address
16000 JOHNSTON MEMORIAL DRIVE
ABINGDON, VA 24211
Medicare Provider Number
490053
Participating Start Date
10/30/2020
Last Recertification Date
9/11/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 700, LLC
Pharmacy Address
5700 DOT COM CT, STE 1000
OVIEDO, FL 32765
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2021
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