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OPTUM PHARMACY 702, LLC
DSH210019 TIDALHEALTH PENINSULA REGIONAL INC
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Covered Entity Details
Entity Name
TIDALHEALTH PENINSULA REGIONAL INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210019
Entity Address
100 EAST CARROLL STREET
SALISBURY, MD 21801
Medicare Provider Number
210019
Participating Start Date
3/15/2022
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Jordan, Senior Director of Pharmacy
(410) 543-7054
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2021
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