Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
CAH181328-00 ARH Mary Breckinridge Health Services, Inc.

Covered Entity Details

Entity Name

ARH Mary Breckinridge Health Services, Inc.

Subdivision Name

Barbourville ARH Hospital

Type

Critical Access Hospital

340B ID

CAH181328-00

Entity Address

80 HOSPITAL DRIVE
BARBOURVILLE, KY 40906

Medicare Provider Number

181328

Participating Start Date

1/1/2016

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

7/9/2020

Contract Begin Date

7/30/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Joseph Grossman, PRESIDENT and CEO
(859) 226-2450

Contract Pharmacy Representative

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

Signed By Date

7/9/2020

340B Drug Pricing Program Database