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OPTUM PHARMACY 702, LLC
DSH160033 GENESIS MEDICAL CENTER - DAVENPORT
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Covered Entity Details
Entity Name
GENESIS MEDICAL CENTER - DAVENPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160033
Entity Address
1227 EAST RUSHOLME
DAVENPORT, IA 52803
Medicare Provider Number
160033
Participating Start Date
1/1/2019
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
10/8/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jordan Voigt, GMC Davenport President
(563) 421-2792
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/8/2021
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