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OPTUM PHARMACY 702, LLC
DSH180045 ST. ELIZABETH FLORENCE
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Covered Entity Details
Entity Name
ST. ELIZABETH FLORENCE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180045
Entity Address
4900 HOUSTON ROAD
FLORENCE, KY 41042-4824
Medicare Provider Number
180045
Participating Start Date
10/1/2016
Last Recertification Date
9/2/2019
Entity Termination Date
10/1/2020
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
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
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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