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OPTUM PHARMACY 701, LLC
DSH100135 TALLAHASSEE MEMORIAL HEALTHCARE, INC
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Covered Entity Details
Entity Name
TALLAHASSEE MEMORIAL HEALTHCARE, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100135
Entity Address
1300 MICCOSUKEE ROAD
TALLAHASSEE, FL 32308
Medicare Provider Number
100135
Participating Start Date
1/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/21/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Priscilla Needham, Chief Financial Officer
(850) 431-0630
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/21/2025
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