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OPTUM PHARMACY 701, LLC
DSH470011 Brattleboro Memorial Hospital
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Covered Entity Details
Entity Name
Brattleboro Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470011
Entity Address
17 Belmont Avenue
Brattleboro, VT 05301
Medicare Provider Number
470011
Participating Start Date
7/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
4/3/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Laura Bruno, Interium Chief Financial Officer
(802) 257-8385
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/3/2025
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