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OPTUM PHARMACY 702, LLC
DSH070024 THE WILLIAM W. BACKUS HOSPITAL
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Covered Entity Details
Entity Name
THE WILLIAM W. BACKUS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070024
Entity Address
326 WASHINGTON STREET
NORWICH, CT 06360
Medicare Provider Number
070024
Participating Start Date
3/13/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
3/13/2023
Contract Begin Date
3/13/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Anthony Mastroianni, Regional Vice President, Finance
(860) 889-8331 Ext: 2311
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
3/9/2023
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