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OPTUM INFUSION SERVICES 500, INC.
RRC070024-00 THE WILLIAM W. BACKUS HOSPITAL
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Covered Entity Details
Entity Name
THE WILLIAM W. BACKUS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC070024-00
Entity Address
326 WASHINGTON STREET
NORWICH, CT 06360
Medicare Provider Number
070024
Participating Start Date
4/1/2025
Last Recertification Date
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 500, INC.
Pharmacy Address
19 CHAPIN RD BLDG D
SUITE D7
PINE BROOK, NJ 07058-9385
Pharmacy Comments
Contract Details
Approval Date
2/12/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Anthony Mastroianni, Regional Vice President, Finance
(860) 889-8331 Ext: 2311
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/9/2025
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