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OPTUM PHARMACY 702, LLC
DSH070011 CHARLOTTE HUNGERFORD HOSPITAL
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Covered Entity Details
Entity Name
CHARLOTTE HUNGERFORD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070011
Entity Address
540 LITCHFIELD STREET
TORRINGTON, CT 06790-0988
Medicare Provider Number
070011
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cheryl Considine, Director Finance, NW Region
(860) 496-6740
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/10/2025
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