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OPTUM PHARMACY 702, LLC
PED443303-00 East Tennessee Children’s Hospital
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Covered Entity Details
Entity Name
East Tennessee Children’s Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED443303-00
Entity Address
2018 Clinch Avenue
Knoxville, TN 37916
Medicare Provider Number
443303
Participating Start Date
7/1/2017
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Caryn Hawthorne, Chief Financial Officer
(865) 541-8154
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2022
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