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OPTUM PHARMACY 702, LLC
DSH100006 ORLANDO HEALTH
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Covered Entity Details
Entity Name
ORLANDO HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100006
Entity Address
52 W. Underwood St
ORLANDO, FL 32806
Medicare Provider Number
100006
Participating Start Date
4/1/2004
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/4/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BERNADETTE SPONG, CFO
(321) 841-5078
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/4/2021
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