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OPTUM PHARMACY 702, LLC
DSH450395 Memorial Medical Center-Livingston
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Covered Entity Details
Entity Name
Memorial Medical Center-Livingston
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450395
Entity Address
1717 Hwy 59 Bypass
Livingston, TX 77351
Medicare Provider Number
450395
Participating Start Date
1/1/2012
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
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/27/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kristina Froese, VP of Operations
(936) 329-8726
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/15/2019
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