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OPTUM PHARMACY 702, LLC
DSH250004 NORTH MISSISSIPPI MEDICAL CENTER
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Covered Entity Details
Entity Name
NORTH MISSISSIPPI MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250004
Entity Address
830 SOUTH GLOSTER ST
TUPELO, MS 38801
Medicare Provider Number
250004
Participating Start Date
1/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
7/29/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRUCE J. TOPPIN, GENERAL COUNSEL, PRIVACY OFFICER & COPORATE SECRETARY
(662) 377-4229
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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