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OPTUM PHARMACY 702, LLC
DSH420051 MCLEOD REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MCLEOD REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420051
Entity Address
555 EAST CHEVES STREET
FLORENCE, SC 29506
Medicare Provider Number
420051
Participating Start Date
7/1/2006
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
S. Fulton Ervin, III, Senior Vice President Finance and Chief Financial Officer
(843) 777-2917
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/16/2024
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