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OPTUM PHARMACY 702, LLC
DSH180025 ST. JOE. - FLAGET
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Covered Entity Details
Entity Name
ST. JOE. - FLAGET
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180025
Entity Address
4305 NEW SHEPHERDSVILLE RD
BARDSTOWN, KY 40004
Medicare Provider Number
180025
Participating Start Date
4/1/2016
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
4/17/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer C Nolan, President
(502) 350-5044
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/17/2019
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