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OPTUM PHARMACY 702, LLC
DSH040007 ST VINCENT INFIRMARY
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Covered Entity Details
Entity Name
ST VINCENT INFIRMARY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040007
Entity Address
#2 ST. VINCENT CIRCLE
ATTN: PHARMACY
LITTLE ROCK, AR 72205
Medicare Provider Number
040007
Participating Start Date
7/1/2003
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shawn Barnett, Market SVP-COO-CFO
(501) 552-3571
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/12/2019
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