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OPTUM PHARMACY 701, LLC
DSH420018 PRISMA HEALTH RICHLAND HOSPITAL
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Covered Entity Details
Entity Name
PRISMA HEALTH RICHLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420018
Entity Address
5 Richland Medical Park Drive
COLUMBIA, SC 29203
Medicare Provider Number
420018
Participating Start Date
8/1/1993
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Bundy, Chief Executive Officer
(803) 296-5782
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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