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OPTUM PHARMACY 702, LLC
DSH390198 MILLCREEK COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MILLCREEK COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390198
Entity Address
5515 Peach Street
ERIE, PA 16509
Medicare Provider Number
390198
Participating Start Date
12/28/2020
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
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
Marcus Chase Babiak, Chief Operating Officer
(814) 868-7733
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/17/2022
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