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OPTUM PHARMACY 701, LLC
DSH450068 Memorial Hermann Texas Medical Center
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Covered Entity Details
Entity Name
Memorial Hermann Texas Medical Center
Subdivision Name
Memorial Hermann Texas Medical Center
Type
Disproportionate Share Hospital
340B ID
DSH450068
Entity Address
6411 Fannin St.
Houston, TX 77030
Medicare Provider Number
450068
Participating Start Date
4/1/1994
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
Matt Pruitt, CFO
(713) 704-0112
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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