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OPTUM PHARMACY 702, LLC
DSH190201 CHRISTUS Lake Area Hospital
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Covered Entity Details
Entity Name
CHRISTUS Lake Area Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190201
Entity Address
4200 NELSON RD
LAKE CHARLES, LA 70605
Medicare Provider Number
190201
Participating Start Date
1/1/2018
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
6/11/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Holland, President and CEO
(337) 491-7730
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/9/2020
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