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OPTUM PHARMACY 702, LLC
DSH360051 MIAMI VALLEY HOSPITAL
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Covered Entity Details
Entity Name
MIAMI VALLEY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360051
Entity Address
ONE WYOMING STREET
DAYTON, OH 45409
Medicare Provider Number
360051
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/8/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Craig Allen Ganger, Chief Financial Officer
(937) 499-9988
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/8/2025
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