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OPTUM PHARMACY 702, LLC
DSH410010 WOMEN & INFANTS HOSPITAL OF RHODE ISLAND
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Covered Entity Details
Entity Name
WOMEN & INFANTS HOSPITAL OF RHODE ISLAND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410010
Entity Address
101 DUDLEY ST.
PROVIDENCE, RI 02905
Medicare Provider Number
410010
Participating Start Date
10/1/2004
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
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark R. Marcantano, President, COO
(401) 274-1122 Ext: 41104
Contract Pharmacy Representative
BriovaRX of Maine
Jeffrey Grosklags, CFO
(952) 205-1000
Signed By Date
10/17/2016
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