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OPTUM PHARMACY 702, LLC
DSH250082 DELTA HEALTH-THE MEDICAL CENTER
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Covered Entity Details
Entity Name
DELTA HEALTH-THE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250082
Entity Address
1400 EAST UNION STREET
GREENVILLE, MS 38703
Medicare Provider Number
250082
Participating Start Date
7/1/2004
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/17/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/9/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Amy Walker, Chief Nursing Officer
(662) 334-2169
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/17/2019
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