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OPTUM PHARMACY 705, LLC
DSH230053 HENRY FORD HOSPITAL
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Covered Entity Details
Entity Name
HENRY FORD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230053
Entity Address
2799 WEST GRAND BLVD
DETROIT, MI 48202
Medicare Provider Number
230053
Participating Start Date
10/1/2002
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
10/19/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Edward Chadwick, EVP, Finance and Admin & CFO
(313) 876-8714
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
10/19/2016
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