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OPTUM PHARMACY 702, LLC
DSH200039 MAINEGENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MAINEGENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200039
Entity Address
35 Medical Center Parkway
Augusta, ME 04330
Medicare Provider Number
200039
Participating Start Date
7/1/2008
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/3/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terrance Brann, Chief Financial Officer
(207) 623-6624
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/3/2018
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