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OPTUM PHARMACY 702, LLC
DSH010164 COOSA VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
COOSA VALLEY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010164
Entity Address
315 W. HICKORY STREET
SYLACAUGA, AL 35150
Medicare Provider Number
010164
Participating Start Date
12/1/2005
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/11/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad McCormick, CFO
(256) 401-4534
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/11/2024
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