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OPTUM PHARMACY 702, LLC
RRC520076-00 BEAVER DAM COMMUNITY HOSPITALS
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Covered Entity Details
Entity Name
BEAVER DAM COMMUNITY HOSPITALS
Subdivision Name
Type
Rural Referral Center
340B ID
RRC520076-00
Entity Address
707 SOUTH UNIVERSITY AVENUE
BEAVER DAM, WI 53916
Medicare Provider Number
520076
Participating Start Date
10/1/2024
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
Janette Townsend, CFO
(775) 750-2197
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/15/2025
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