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OPTUM PHARMACY 701, LLC
RRC390079-00 ROBERT PACKER HOSPITAL
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Covered Entity Details
Entity Name
ROBERT PACKER HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC390079-00
Entity Address
ONE GUTHRIE SQUARE
SAYRE, PA 18840
Medicare Provider Number
390079
Participating Start Date
1/1/2018
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
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew David Denniston, VP, Pharmacy Services
(570) 887-6626
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/15/2025
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