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OPTUM PHARMACY 702, LLC
SCH520088-00 SSM HEALTH ST AGNES HOSPITAL - FOND DU LAC
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Covered Entity Details
Entity Name
SSM HEALTH ST AGNES HOSPITAL - FOND DU LAC
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520088-00
Entity Address
430 EAST DIVISION STREET
FOND DU LAC, WI 54935
Medicare Provider Number
520088
Participating Start Date
10/1/2023
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/12/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matt Kinsella, Regional Vice President of Finance
(608) 250-1194
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2023
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