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OPTUM PHARMACY 702, LLC
DSH250001 University of Mississippi Medical Center
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Covered Entity Details
Entity Name
University of Mississippi Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250001
Entity Address
2500 NORTH STATE ST.
JACKSON, MS 39216
Medicare Provider Number
250001
Participating Start Date
4/1/1998
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeffrey Grimsley, CFO-Health System
(601) 815-6270
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/15/2018
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