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OPTUM PHARMACY 701, LLC
DSH250077 WAYNE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
WAYNE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250077
Entity Address
950 MATTHEW DRIVE
WAYNESBORO, MS 39367
Medicare Provider Number
250077
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/8/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andrew Porter, CEO
(601) 735-5151 Ext: 100
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/8/2025
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