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OPTUM PHARMACY 702, LLC
DSH150169 COMMUNITY HOSPITAL OF INDIANA INC.
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Covered Entity Details
Entity Name
COMMUNITY HOSPITAL OF INDIANA INC.
Subdivision Name
Community Hospital North
Type
Disproportionate Share Hospital
340B ID
DSH150169
Entity Address
7150 CLEARVISTA DRIVE
INDIANAPOLIS, IN 46256
Medicare Provider Number
150169
Participating Start Date
4/1/2016
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/7/2021
Contract Begin Date
1/18/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/26/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Kiley, President
(317) 621-9337
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/7/2021
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