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OPTUM PHARMACY 702, LLC
DSH210043 BALTIMORE WASHINGTON MEDICAL CENTER
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Covered Entity Details
Entity Name
BALTIMORE WASHINGTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210043
Entity Address
301 HOSPITAL DRIVE
GLEN BURNIE, MD 21061
Medicare Provider Number
210043
Participating Start Date
1/1/2025
Last Recertification Date
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/5/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Alfred Alan Pietsch, SVP & CFO
(410) 787-4160
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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