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OPTUM PHARMACY 702, LLC
DSH370106 INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
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Covered Entity Details
Entity Name
INTEGRIS SOUTH OKLAHOMA CITY HOSPITAL CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370106
Entity Address
4401 SOUTH WESTERN AVE
OKLAHOMA CITY, OK 73109
Medicare Provider Number
370106
Participating Start Date
7/1/2009
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chris Hammes, Executive Vice President
(405) 949-3400
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2020
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