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OPTUM PHARMACY 702, LLC
RRC230117-00 ASCENSION BORGESS HOSPITAL
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Covered Entity Details
Entity Name
ASCENSION BORGESS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230117-00
Entity Address
1521 GULL ROAD
KALAMAZOO, MI 49048
Medicare Provider Number
230117
Participating Start Date
1/1/2024
Last Recertification Date
8/20/2024
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
Michael McCullough, CFO
(586) 753-0653
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/11/2024
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