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OPTUM PHARMACY 702, LLC
DSH450801 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450801
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
4/1/2015
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
4/9/2020
Contract Begin Date
6/11/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Rounds, Interim President and CEO
(903) 614-2003
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/9/2020
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