Contract Pharmacy Details

OPTUM PHARMACY 701, LLC
DSH520136 Ascension SE Wisconsin Hospital, Inc.

Covered Entity Details

Entity Name

Ascension SE Wisconsin Hospital, Inc.

Subdivision Name

ST. JOSEPH CAMPUS

Type

Disproportionate Share Hospital

340B ID

DSH520136

Entity Address

5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210

Medicare Provider Number

520136

Participating Start Date

4/1/2004

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 701, LLC

Pharmacy Address

4100 S SAGINAW ST STE D
FLINT, MI 48507

Pharmacy Comments

Contract Details

Approval Date

4/29/2022

Contract Begin Date

5/3/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Contract Pharmacy Representative

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

Signed By Date

4/29/2022

340B Drug Pricing Program Database