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OPTUM PHARMACY 702, LLC
RRC450571-00 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450571-00
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
1/1/2021
Last Recertification Date
Entity Termination Date
7/1/2021
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joseph Wooldridge, Chief Financial Officer
(325) 657-5303
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/15/2021
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