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OPTUM INFUSION SERVICES 200, INC
DSH420078 Prisma Health GREENVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Prisma Health GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420078
Entity Address
701 GROVE ROAD
GREENVILLE, SC 29605
Medicare Provider Number
420078
Participating Start Date
4/1/1999
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 200, INC
Pharmacy Address
5895 CORE RD
STE 417
NORTH CHARLESTON, SC 29406
Pharmacy Comments
Contract Details
Approval Date
7/25/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Barrett Ludley, CFO
(864) 455-6405
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/25/2023
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