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OPTUM PHARMACY 702, LLC
RRC450011-00 ST. JOSEPH REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
ST. JOSEPH REGIONAL HEALTH CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450011-00
Entity Address
2801 FRANCISCAN DRIVE
BRYAN, TX 77802-2544
Medicare Provider Number
450011
Participating Start Date
10/1/2018
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/14/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ricardo Diaz, Chief Operating Officer
(979) 776-2580
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/14/2019
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