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OPTUM PHARMACY 701, LLC
DSH110091 Piedmont Rockdale Hospital, Inc.
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Covered Entity Details
Entity Name
Piedmont Rockdale Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110091
Entity Address
1412 Milstead Ave NE
CONYERS, GA 30012
Medicare Provider Number
110091
Participating Start Date
4/1/2019
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/7/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stewart Witherell, CFO
(770) 918-3101
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/7/2025
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