Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RRC450032-00 GOOD SHEPHERD MEDICAL CENTER

Covered Entity Details

Entity Name

GOOD SHEPHERD MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

340B ID

RRC450032-00

Entity Address

811 SOUTH WASHINGTON
MARSHALL, TX 75670

Medicare Provider Number

450032

Participating Start Date

11/30/2020

Last Recertification Date

8/18/2021

Entity Termination Date

7/1/2022

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

11/3/2020

Contract Begin Date

12/2/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2022
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Michael Cheek, CFO
(903) 315-1814

Contract Pharmacy Representative

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

Signed By Date

10/9/2020

340B Drug Pricing Program Database