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OPTUM PHARMACY 702, LLC
CAH521328-00 MARSHFIELD MEDICAL CENTER LADYSMITH
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Covered Entity Details
Entity Name
MARSHFIELD MEDICAL CENTER LADYSMITH
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521328-00
Entity Address
1200 Port Arthur Road
LADYSMITH, WI 54848
Medicare Provider Number
521328
Participating Start Date
10/1/2019
Last Recertification Date
8/20/2024
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
Michele Seator, VP-Operations and Patient Care Service-Ladysmith
(715) 609-3313
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/15/2025
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