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OPTUM PHARMACY 702, LLC
DSH060022 Memorial Health System
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Covered Entity Details
Entity Name
Memorial Health System
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH060022
Entity Address
1400 EAST BOULDER STREET
COLORADO SPRINGS, CO 80909
Medicare Provider Number
060022
Participating Start Date
7/1/2004
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/9/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doreen Matson, Chief Financial Officer
(719) 365-2062
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/9/2023
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