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OPTUM PHARMACY 702, LLC
DSH110076 DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL
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Covered Entity Details
Entity Name
DEKALB MEDICAL CENTER, INC - DBA EMORY DECATUR HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110076
Entity Address
2701 NORTH DECATUR ROAD
DECATUR, GA 30033
Medicare Provider Number
110076
Participating Start Date
4/1/2002
Last Recertification Date
8/23/2024
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
Lisa Urbistondo, Vice President & CFO
(404) 501-5025
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/15/2025
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