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OPTUM PHARMACY 701, LLC
DSH340047 NORTH CAROLINA BAPTIST HOSPITAL
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Covered Entity Details
Entity Name
NORTH CAROLINA BAPTIST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340047
Entity Address
MEDICAL CENTER BOULEVARD
WINSTON-SALEM, NC 27157
Medicare Provider Number
340047
Participating Start Date
4/1/1998
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
4/20/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Thomas Waid, Sr Vice President - Health System Operations and Integration
(336) 716-0433
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/20/2025
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