Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RRC450102-00 CHRISTUS MOTHER FRANCES HOSP-TYLER

Covered Entity Details

Entity Name

CHRISTUS MOTHER FRANCES HOSP-TYLER

Subdivision Name

Type

Rural Referral Center

340B ID

RRC450102-00

Entity Address

800 EAST DAWSON ST.
TYLER, TX 75701

Medicare Provider Number

450102

Participating Start Date

8/13/2020

Last Recertification Date

8/20/2021

Entity Termination Date

3/10/2022

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

10/7/2020

Contract Begin Date

10/14/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Elizabeth Pulliam, Chief Financial Officer
(903) 606-4102

Contract Pharmacy Representative

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

Signed By Date

10/7/2020

340B Drug Pricing Program Database