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OPTUM PHARMACY 702, LLC
CAH471303-00 NORTHEASTERN VERMONT REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
NORTHEASTERN VERMONT REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH471303-00
Entity Address
1315 HOSPITAL DRIVE
ST JOHNSBURY, VT 05819
Medicare Provider Number
471303
Participating Start Date
9/28/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert Hersey, CFO
(802) 748-7530
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2022
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