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OPTUM PHARMACY 702, LLC
RRC110074-00 PIEDMONT ATHENS REGIONAL MEDICAL CE
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Covered Entity Details
Entity Name
PIEDMONT ATHENS REGIONAL MEDICAL CE
Subdivision Name
Type
Rural Referral Center
340B ID
RRC110074-00
Entity Address
1199 PRINCE AVENUE
ATHENS, GA 30306
Medicare Provider Number
110074
Participating Start Date
12/4/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/21/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Justin Roberts, CFO
(706) 475-3463
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2024
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