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OPTUM PHARMACY 702, LLC
CAH521325-00 FLAMBEAU HOSPITAL INC.
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Covered Entity Details
Entity Name
FLAMBEAU HOSPITAL INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521325-00
Entity Address
98 SHERRY AVENUE
PARK FALLS, WI 54552-0310
Medicare Provider Number
521325
Participating Start Date
7/1/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ty Erickson, President-MMC-Minocqua/Park Falls
(715) 358-1299 Ext: 1704
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/14/2025
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