Contract Pharmacy Details

OPTUM INFUSION SERVICES 500, INC.
DSH100017 HALIFAX HEALTH MEDICAL CENTER

Covered Entity Details

Entity Name

HALIFAX HEALTH MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH100017

Entity Address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH, FL 32114

Medicare Provider Number

100017

Participating Start Date

1/1/2009

Last Recertification Date

8/26/2024

Pharmacy Details

Pharmacy Name

OPTUM INFUSION SERVICES 500, INC.

Pharmacy Address

4900 RIVERGRADE RD STE E120
IRWINDALE, CA 91706-1419

Pharmacy Comments

Contract Details

Approval Date

1/20/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/30/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

ERIC M. PEBURN, CFO
(386) 425-4568

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

1/20/2022

340B Drug Pricing Program Database