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OPTUM PHARMACY 704, INC.
DSH450573 CHRISTUS JASPER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CHRISTUS JASPER MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450573
Entity Address
1275 MARVIN HANCOCK DRIVE
JASPER, TX 75951
Medicare Provider Number
450573
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
6/8/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Nikki Martin, Regional Director, Finance
(409) 899-7105
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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