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OPTUM PHARMACY 702, LLC
DSH450828 CHRISTUS SPOHN HOSPITAL ALICE
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Covered Entity Details
Entity Name
CHRISTUS SPOHN HOSPITAL ALICE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450828
Entity Address
2500 EAST MAIN ST.
ALICE, TX 78332
Medicare Provider Number
450828
Participating Start Date
9/16/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
6/10/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/23/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Becky Rios, Interim CFO
(361) 881-3157
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/13/2020
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