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OPTUM PHARMACY 702, LLC
PED453315-00 CHRISTUS Children's
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Covered Entity Details
Entity Name
CHRISTUS Children's
Subdivision Name
Type
Children's Hospital
340B ID
PED453315-00
Entity Address
333 North Santa Rosa Street
San Antonio, TX 78207
Medicare Provider Number
453315
Participating Start Date
4/1/2014
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
4/10/2020
Contract Begin Date
6/8/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephanie Parker, VP Finance
(210) 704-3657
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/10/2020
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