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OPTUM PHARMACY 702, LLC
DSH440073 MAURY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
MAURY REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440073
Entity Address
1224 TROTWOOD AVENUE
COLUMBIA, TN 38401
Medicare Provider Number
440073
Participating Start Date
7/20/2022
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
9/29/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Martin Chaney, Chief Executive Officer
(931) 380-4008
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
9/29/2022
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