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OPTUM PHARMACY 702, LLC
CAH241325-00 CCM Health
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Covered Entity Details
Entity Name
CCM Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241325-00
Entity Address
824 N 11Th St
Montevideo, MN 56265
Medicare Provider Number
241325
Participating Start Date
1/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Lovdahl, CEO
(320) 321-8101
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2021
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