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OPTUM PHARMACY 702, LLC
DSH490045 UVA HEALTH PRINCE WILLIAM MEDICAL CENTER
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Covered Entity Details
Entity Name
UVA HEALTH PRINCE WILLIAM MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490045
Entity Address
8700 SUDLEY ROAD
MANASSAS, VA 20110
Medicare Provider Number
490045
Participating Start Date
10/1/2018
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/13/2023
Contract Begin Date
2/14/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Wilmoth, Strategic Planning and Reimbursement Officer
(434) 243-9802
Contract Pharmacy Representative
Optum
Nancy McCutcheon, Sr. VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2023
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