Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
CAH191302-00 ST. MARTIN HOSPITAL

Covered Entity Details

Entity Name

ST. MARTIN HOSPITAL

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH191302-00

Entity Address

210 CHAMPAGNE BLVD.
BREAUX BRIDGE, LA 70517

Medicare Provider Number

191302

Participating Start Date

9/28/2010

Last Recertification Date

8/27/2024

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

10/23/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Glenn Dailey, CEO
(337) 507-1201

Contract Pharmacy Representative

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

Signed By Date

10/15/2020

340B Drug Pricing Program Database