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OPTUM INFUSION SERVICES 204, INC
DSH100157 LAKELAND REGIONAL MED CTR
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Covered Entity Details
Entity Name
LAKELAND REGIONAL MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100157
Entity Address
1324 LAKELAND HILLS BLVD
LAKELAND, FL 33805
Medicare Provider Number
100157
Participating Start Date
1/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 204, INC
Pharmacy Address
8509 BENJAMIN RD STE A
TAMPA, FL 33634-1224
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lance Green, EVP/Chief Financial Officer
(863) 687-1100 Ext: 5225
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/12/2023
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