Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
SCH260006-00 HEARTLAND REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

HEARTLAND REGIONAL MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH260006-00

Entity Address

5325 FARAON
ST. JOSEPH, MO 64506-3398

Medicare Provider Number

260006

Participating Start Date

10/1/2020

Last Recertification Date

8/30/2023

Entity Termination Date

1/1/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

8/17/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Dwain Stilson, Chief Financial Officer
(816) 271-7070

Contract Pharmacy Representative

Briova
Joseph L Lovino, Manager, 340B Specialty Program
(412) 445-4495

Signed By Date

8/6/2020

340B Drug Pricing Program Database