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OPTUM PHARMACY 702, LLC
DSH220163 UMASS MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
UMASS MEMORIAL MEDICAL CENTER
Subdivision Name
UNIVERSITY CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH220163
Entity Address
55 LAKE AVENUE NORTH
WORCESTER, MA 01655
Medicare Provider Number
220163
Participating Start Date
10/1/2003
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/13/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alice Shakman, Vice President Operations
(774) 443-0540
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/13/2018
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