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OPTUM PHARMACY 702, LLC
PED243300-00 GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
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Covered Entity Details
Entity Name
GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Subdivision Name
Type
Children's Hospital
340B ID
PED243300-00
Entity Address
200 UNIVERSITY AVENUE EAST
ST. PAUL, MN 55101
Medicare Provider Number
243300
Participating Start Date
7/1/2019
Last Recertification Date
8/19/2024
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
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Patrick Michael Nolan, Chief Financial Officer
(651) 312-3105
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/17/2023
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