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OPTUM PHARMACY 705, LLC
CAH451319-00 MOTHER FRANCES HOSPITAL-JACKSONVILLE
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Covered Entity Details
Entity Name
MOTHER FRANCES HOSPITAL-JACKSONVILLE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451319-00
Entity Address
2026 S.JACKSON ST.
JACKSONVILLE, TX 75766
Medicare Provider Number
451319
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
4/21/2020
Contract Begin Date
6/8/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Barry D. Lofquist, Administrator
(903) 541-4505
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
4/21/2020
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