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OPTUM PHARMACY 705, LLC
DSH340091 THE MOSES H CONE MEMORIAL HOSPITAL OPERATING CORPORATION
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Covered Entity Details
Entity Name
THE MOSES H CONE MEMORIAL HOSPITAL OPERATING CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340091
Entity Address
1200 NORTH ELM STREET
GREENSBORO, NC 27401-1020
Medicare Provider Number
340091
Participating Start Date
4/1/2006
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
10/15/2021
Contract Begin Date
10/28/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andrew Barrow, Chief Financial Officer
(336) 832-7825
Contract Pharmacy Representative
BriovaRX of Maine
Jeffrey Grosklags, CFO
(952) 205-1000
Signed By Date
10/15/2021
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