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OPTUM PHARMACY 705, LLC
SCH360125-00 Ashtabula County Medical Center
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Covered Entity Details
Entity Name
Ashtabula County Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH360125-00
Entity Address
2420 Lake Avenue
Ashtabula, OH 44004
Medicare Provider Number
360125
Participating Start Date
1/1/2012
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Richard Trice, VP of Clinical Services
(440) 997-6771
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/17/2022
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