Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
DSH190111 WILLIS KNIGHTON MEDICAL CENTER, INC.

Covered Entity Details

Entity Name

WILLIS KNIGHTON MEDICAL CENTER, INC.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH190111

Entity Address

2600 GREENWOOD ROAD
SHREVEPORT, LA 71103

Medicare Provider Number

190111

Participating Start Date

1/1/2007

Last Recertification Date

8/17/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

4/15/2020

Contract Begin Date

4/24/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Mary Jane Ward, Senior Vice President - CFO
(318) 212-4384

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

4/15/2020

340B Drug Pricing Program Database