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OPTUM PHARMACY 705, LLC
DSH260113 MISSOURI DELTA MEDICAL CENTER
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Covered Entity Details
Entity Name
MISSOURI DELTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260113
Entity Address
1008 NORTH MAIN
SIKESTON, MO 63801
Medicare Provider Number
260113
Participating Start Date
7/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
11142 RENNER BLVD
LENEXA, KS 66219
Pharmacy Comments
Contract Details
Approval Date
7/10/2020
Contract Begin Date
7/20/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
JASON SCHRUMPF, CEO
(573) 472-7600
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/10/2020
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