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OPTUM PHARMACY 702, LLC
DSH220095 HENRY HEYWOOD MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
HENRY HEYWOOD MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220095
Entity Address
242 GREEN STREET
GARDNER, MA 01440
Medicare Provider Number
220095
Participating Start Date
4/1/2025
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
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Bujak, Chief Financial Officer
(978) 630-6202
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/15/2025
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