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OPTUM PHARMACY 702, LLC
DSH360054 HOLZER
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Covered Entity Details
Entity Name
HOLZER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360054
Entity Address
100 JACKSON PIKE
GALLIPOLIS, OH 45631
Medicare Provider Number
360054
Participating Start Date
7/1/2006
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/22/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael P Haynes, EVP/CFO
(740) 446-5743
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/22/2024
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