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OPTUM PHARMACY 702, LLC
DSH010078 NORTHEAST ALABAMA REGIONAL MED CTR
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Covered Entity Details
Entity Name
NORTHEAST ALABAMA REGIONAL MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010078
Entity Address
400 EAST TENTH STREET
ANNISTON, AL 36207
Medicare Provider Number
010078
Participating Start Date
1/1/2016
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
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark North, Vice President - Finance/CFO
(256) 741-6370
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
1/12/2024
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