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OPTUM PHARMACY 702, LLC
CAH301305-00 ALICE PECK DAY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ALICE PECK DAY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH301305-00
Entity Address
10 ALICE PECK DAY DRIVE
LEBANON, NH 03766
Medicare Provider Number
301305
Participating Start Date
4/1/2020
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/18/2021
Contract Begin Date
10/21/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Todd P Roberts, CFO
(603) 308-0082
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/18/2021
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