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OPTUM PHARMACY 702, LLC
CAH221303-00 Athol Memorial Hospital
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Covered Entity Details
Entity Name
Athol Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH221303-00
Entity Address
2033 Main St.
Athol, MA 01331
Medicare Provider Number
221303
Participating Start Date
4/1/2013
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
4/24/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tom Sullivan, CFO
(978) 630-6157
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/17/2023
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