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OPTUM INFUSION SERVICES 204, INC.
DSH100135 TALLAHASSEE MEMORIAL HEALTHCARE, INC
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Covered Entity Details
Entity Name
TALLAHASSEE MEMORIAL HEALTHCARE, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100135
Entity Address
1300 MICCOSUKEE ROAD
TALLAHASSEE, FL 32308
Medicare Provider Number
100135
Participating Start Date
1/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 204, INC.
Pharmacy Address
826 CREIGHTON RD, UNIT A-103
PENSACOLA, FL 32504
Pharmacy Comments
Contract Details
Approval Date
4/19/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/5/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
WILLIAM A. GIUDICE, CHIEF FINANCIAL OFFICER
(850) 431-5238
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/19/2022
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