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OPTUM PHARMACY 702, LLC
CAH511311-00 HAMPSHIRE MEMORIAL HOSPITAL, INC.
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Covered Entity Details
Entity Name
HAMPSHIRE MEMORIAL HOSPITAL, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511311-00
Entity Address
363 Sunrise Boulevard
ROMNEY, WV 26757
Medicare Provider Number
511311
Participating Start Date
9/13/2010
Last Recertification Date
8/23/2024
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
10/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Peter F. Gallagher, CFO
(540) 536-8031
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2021
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