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OPTUM PHARMACY 705, LLC
CAH231328-00 Ascension Borgess Allegan Hospital
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Covered Entity Details
Entity Name
Ascension Borgess Allegan Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231328-00
Entity Address
555 LINN STREET
ALLEGAN, MI 49010
Medicare Provider Number
231328
Participating Start Date
9/2/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/11/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/13/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robert Walter Mach, Administrator
(269) 249-7955
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/11/2022
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