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OPTUM PHARMACY 705, LLC
SCH260050-00 Mosaic Medical Center Maryville
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Covered Entity Details
Entity Name
Mosaic Medical Center Maryville
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260050-00
Entity Address
2016 S. Main
Maryville, MO 64468
Medicare Provider Number
260050
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/11/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/17/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Baumgartner, President
(660) 562-7900
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/11/2018
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