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OPTUM PHARMACY 702, LLC
DSH440176 INDIAN PATH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
INDIAN PATH COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440176
Entity Address
2000 BROOKSIDE DRIVE
KINGSPORT, TN 37660-4627
Medicare Provider Number
440176
Participating Start Date
10/1/2015
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
10/19/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shane Hilton, VP/CFO - Market Operations
(423) 302-3467
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/19/2020
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