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OPTUM PHARMACY 702, LLC
SCH230055-00 Marshfield Medical Center - Dickinson
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Covered Entity Details
Entity Name
Marshfield Medical Center - Dickinson
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230055-00
Entity Address
1721 S. Stephenson Avenue
Iron Mountain, MI 49801
Medicare Provider Number
230055
Participating Start Date
7/1/2017
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/4/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Susan Hadley, Director of Nursing
(906) 776-5596
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/4/2018
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