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OPTUM PHARMACY 702, LLC
DSH360096 EAST LIVERPOOL CITY HOSPITAL
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Covered Entity Details
Entity Name
EAST LIVERPOOL CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360096
Entity Address
425 WEST FIFTH STREET
EAST LIVERPOOL, OH 43920
Medicare Provider Number
360096
Participating Start Date
7/1/2015
Last Recertification Date
8/20/2024
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
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/20/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Keith Richardson, CEO
(330) 386-2002
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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