Provider Demographics
NPI:1154306801
Name:OPTUM PHARMACY 705, LLC
Entity Type:Organization
Organization Name:OPTUM PHARMACY 705, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:11000 OPTUM CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:800-328-5979
Mailing Address - Fax:
Practice Address - Street 1:1100 LEE BRANCH LN
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-7298
Practice Address - Country:US
Practice Address - Phone:205-995-8388
Practice Address - Fax:205-995-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
AL1122833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128765OtherPK
4870330001Medicare NSC