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OPTUM PHARMACY 701, LLC
DSH420078 Prisma Health GREENVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Prisma Health GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420078
Entity Address
701 GROVE ROAD
GREENVILLE, SC 29605
Medicare Provider Number
420078
Participating Start Date
4/1/1999
Last Recertification Date
9/4/2024
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
Barrett Ludley, CFO
(864) 455-6405
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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