Contract Pharmacy Details

OPTUM PHARMACY 806, INC.
RRC140034-00 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Covered Entity Details

Entity Name

ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140034-00

Entity Address

400 NORTH PLEASANT AVENUE
CENTRALIA, IL 62801

Medicare Provider Number

140034

Participating Start Date

4/1/2011

Last Recertification Date

9/19/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 806, INC.

Pharmacy Address

2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618

Pharmacy Comments

Contract Details

Approval Date

7/22/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/10/2023
Pharmacy closed

Contacts

Covered Entity Signing Official

Damon Harbison, President
(618) 436-8000

Contract Pharmacy Representative

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

Signed By Date

7/22/2020

340B Drug Pricing Program Database