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OPTUM PHARMACY 701, LLC
DSH490022 MARY WASHINGTON HOSPITAL
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Covered Entity Details
Entity Name
MARY WASHINGTON HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490022
Entity Address
1001 SAM PERRY BLVD
FREDERICKSBURG, VA 22401
Medicare Provider Number
490022
Participating Start Date
7/1/2024
Last Recertification Date
8/15/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
10/10/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/2/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sean Timothy Barden, Executive VP & CFO
(540) 741-1494
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/10/2024
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