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OPTUM PHARMACY 702, LLC
DSH090011 MEDSTAR WASHINGTON HOSPITAL CENTER
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Covered Entity Details
Entity Name
MEDSTAR WASHINGTON HOSPITAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH090011
Entity Address
110 IRVING STREET, NW
WASHINGTON, DC 20010
Medicare Provider Number
090011
Participating Start Date
1/1/2005
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
1/19/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William J Gayne, Chief Financial Officer
(202) 877-6147
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2022
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