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OPTUM PHARMACY 702, LLC
DSH260005AA SSM HEALTH ST. JOSEPH HOSPITAL- SC
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Covered Entity Details
Entity Name
SSM HEALTH ST. JOSEPH HOSPITAL- SC
Subdivision Name
SCCMG St. Peters IM/FP
Type
Disproportionate Share Hospital
340B ID
DSH260005AA
Entity Address
6994 Mexico Road
St. Peters, MO 63376
Medicare Provider Number
260005
Outpatient Facility Provider Number
260005
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Karen D. Rewerts, Regional VP of Financa/CFO
(314) 989-2034
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/10/2018
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