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OPTUM PHARMACY 702, LLC
DSH360189 MADISON HEALTH
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Covered Entity Details
Entity Name
MADISON HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360189
Entity Address
210 NORTH MAIN STREET
LONDON, OH 43140
Medicare Provider Number
360189
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/9/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael S. Browning, Chief Financial Officer
(740) 845-7015
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/9/2024
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