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OPTUM PHARMACY 702, LLC
DSH180001 ST ELIZABETH FT THOMAS
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Covered Entity Details
Entity Name
ST ELIZABETH FT THOMAS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180001
Entity Address
85 NORTH GRAND AVENUE
FT. THOMAS, KY 41075-1793
Medicare Provider Number
180001
Participating Start Date
3/15/2022
Last Recertification Date
8/25/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Ritchey-Baldwin, CFO
(859) 655-1642
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/15/2019
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