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OPTUM PHARMACY 702, LLC
DSH210037 MEMORIAL EASTON
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Covered Entity Details
Entity Name
MEMORIAL EASTON
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210037
Entity Address
MEMORIAL HOSPITAL AT EASTON
219 SOUTH WASHINGTON STREET, MD 21601
Medicare Provider Number
210037
Participating Start Date
10/1/2022
Last Recertification Date
9/7/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
8/9/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kenneth Kozel, President and CEO
(410) 822-1000 Ext: 5500
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2022
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