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OPTUM PHARMACY 702, LLC
HM04101 MAINE MEDICAL CENTER
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Covered Entity Details
Entity Name
MAINE MEDICAL CENTER
Subdivision Name
MAINE HEMOPHILIA AND THROMBOSIS CENTER
Type
Comprehensive Hemophilia Treatment Center
340B ID
HM04101
Entity Address
22 BRAMHALL ST
PORTLAND, ME 04101
Grant Number
H30MC24048
Participating Start Date
4/1/2008
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/6/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lugene Anthony Inzana, CFO
(207) 662-2654
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/6/2023
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