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OPTUM PHARMACY 702, LLC
PED103304-00 NEMOURS CHILDRENS HOSPITAL
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Covered Entity Details
Entity Name
NEMOURS CHILDRENS HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED103304-00
Entity Address
6535 NEMOURS PARKWAY
ORLANDO, FL 32827
Medicare Provider Number
103304
Participating Start Date
4/1/2017
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
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
Hal Williams, Operational Vice President Central Florida Finance
(407) 650-7456
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/17/2022
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