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OPTUM PHARMACY 702, LLC
DSH510030 Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
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Covered Entity Details
Entity Name
Davis Memorial Hospital DBA DAVIS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510030
Entity Address
812 Gorman Avenue
ELKINS, WV 26241
Medicare Provider Number
510030
Participating Start Date
1/1/2005
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William Lloyd Koch, Director of Financial Operations
(304) 637-3196
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2023
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