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OPTUM PHARMACY 701, LLC
DSH100157 LAKELAND REGIONAL MED CTR
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Covered Entity Details
Entity Name
LAKELAND REGIONAL MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100157
Entity Address
1324 LAKELAND HILLS BLVD
LAKELAND, FL 33805
Medicare Provider Number
100157
Participating Start Date
1/1/2020
Last Recertification Date
8/19/2024
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
Lance Green, EVP/Chief Financial Officer
(863) 687-1100 Ext: 5225
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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