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OPTUM PHARMACY 702, LLC
DSH240071 Allina Health Faribault Medical Center
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Covered Entity Details
Entity Name
Allina Health Faribault Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240071
Entity Address
200 STATE AVENUE
FARIBAULT, MN 55021
Medicare Provider Number
240071
Participating Start Date
1/1/2016
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
4/10/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tony M Collins-Kwong, Director, Strategic Sourcing and Services, Pharmacy Services
(612) 262-4785
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/10/2023
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