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OPTUM PHARMACY 702, LLC
DSH180079 HARRISON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
HARRISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180079
Entity Address
1210 KY HIGHWAY 36 E
CYNTHIANA, KY 41031
Medicare Provider Number
180079
Participating Start Date
9/9/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/11/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID MELLETT, CFO
(859) 235-3502
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/11/2021
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