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OPTUM PHARMACY 705, LLC
DSH030016 Banner Casa Grande Medical Center
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Covered Entity Details
Entity Name
Banner Casa Grande Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030016
Entity Address
1800 East Florence Blvd.
Casa Grande, AZ 85122
Medicare Provider Number
030016
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
1/17/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Louis Schroeder, Chief Financial Officer
(520) 381-6529
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/17/2022
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