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OPTUM PHARMACY 702, LLC
DSH490002 RUSSELL COUNTY HOSPITAL
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Covered Entity Details
Entity Name
RUSSELL COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490002
Entity Address
58 Carroll Street
LEBANON, VA 24266
Medicare Provider Number
490002
Participating Start Date
4/22/2020
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shane Hilton, EVP, Chief Financial Officer
(423) 302-3467
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2020
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