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OPTUM PHARMACY 702, LLC
DSH420018 PRISMA HEALTH RICHLAND HOSPITAL
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Covered Entity Details
Entity Name
PRISMA HEALTH RICHLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420018
Entity Address
5 Richland Medical Park Drive
COLUMBIA, SC 29203
Medicare Provider Number
420018
Participating Start Date
8/1/1993
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/19/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert Haarbauer Cofield, Chief Executive Officer
(803) 434-3750
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/19/2021
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