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OPTUM PHARMACY 702, LLC
DSH150007 COMMUNITY HOWARD REGIONAL HEALTH
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Covered Entity Details
Entity Name
COMMUNITY HOWARD REGIONAL HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150007
Entity Address
3500 SOUTH LAFOUNTAIN
KOKOMO, IN 46902
Medicare Provider Number
150007
Participating Start Date
1/1/2016
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
1/11/2021
Contract Begin Date
1/18/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Hooper, President & CEO
(765) 776-8580
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/11/2021
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