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OPTUM PHARMACY 702, LLC
DSH450184 MEMORIAL HERMANN HOSPITAL SYSTEM
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Covered Entity Details
Entity Name
MEMORIAL HERMANN HOSPITAL SYSTEM
Subdivision Name
Memorial Hermann Southwest Hospital
Type
Disproportionate Share Hospital
340B ID
DSH450184
Entity Address
7600 Beechnut
Houston, TX 77074
Medicare Provider Number
450184
Participating Start Date
2/7/2018
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
7/28/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rebecca Tucker, VP, Finance
(713) 456-5340
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/14/2020
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