OPTUM PHARMACY 801, INC.

Provider Demographics

• NPI: 1649317579
• Name: OPTUM PHARMACY 801, INC.
• Entity type: Organization
• Organization Name: OPTUM PHARMACY 801, INC.
• Authorized Official - Title/Position: SECRETARY
• Authorized Official - First Name: KEVIN
• Authorized Official - Middle Name: EUGENE
• Authorized Official - Last Name: BURR
• Authorized Official - Phone: 712-310-4701
• Mailing Address - Street 1: 1 OPTUM CIR STE 100
• 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
• Practice Address - Street 1: 23620 N 20TH DR
• Practice Address - Street 2: STE 12
• Practice Address - City: PHOENIX
• Practice Address - State: AZ
• Practice Address - Zip Code: 85085-0621
• Practice Address - Country: US
• Practice Address - Phone: 877-546-5779
• Practice Address - Fax: 877-546-5780
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: APOTHECARY HOLDINGS INC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2007-01-31
• Last Update Date: 2024-12-04

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	333600000X	Suppliers	Pharmacy
No	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy
No	3336C0004X	Suppliers	Pharmacy	Compounding Pharmacy
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy
No	3336M0002X	Suppliers	Pharmacy	Mail Order Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MS	04189372	Medicaid
WA	1092352	Medicaid
NV	1649317579	Medicaid
KS	200587210A	Medicaid
ME	435869100	Medicaid
NJ	0248029	Medicaid
NE	10026395600	Medicaid
NC	1649317579	Medicaid
SC	7A5084	Medicaid
CA	1649317579	Medicaid
UT	1649317579	Medicaid
OR	279375	Medicaid
OH	2903933	Medicaid
MN	908430000	Medicaid
MD	012525200	Medicaid
NJ	0248886	Medicaid
PA	102243468 0001	Medicaid
MI	1649317579	Medicaid
OK	200227450 A	Medicaid
CT	008008147	Medicaid
MT	1649317579	Medicaid
NM	46929568	Medicaid
KY	7100191550	Medicaid
AK	1028406	Medicaid
TN	1526920	Medicaid
VA	1649317579	Medicaid
IN	200920700A	Medicaid
AZ	224039	Medicaid
VT	1016059	Medicaid
MA	110122540A	Medicaid
AK	1575637	Medicaid
HI	1649317579	Medicaid
WV	3810016588	Medicaid
MD	418360600	Medicaid
NM	87136031	Medicaid
CO	95522735	Medicaid
AL	109600	Medicaid
IA	1649317579	Medicaid
WI	1649317579	Medicaid
ID	808246800	Medicaid
SC	DM1333	Medicaid
OK	200227450 A	Medicaid
OK	200227450 A	Medicaid
ID	808246800	Medicaid