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OPTUM PHARMACY 702, LLC
CAH231325-00 MyMichigan Medical Center Gladwin
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Covered Entity Details
Entity Name
MyMichigan Medical Center Gladwin
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231325-00
Entity Address
515 QUARTER STREET
GLADWIN, MI 48624
Medicare Provider Number
231325
Participating Start Date
8/31/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ray Stover, Regional President
(989) 246-6203
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
1/17/2023
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