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OPTUM PHARMACY 702, LLC
DSH450867 Ascension Seton d/b/a Ascension Seton Northwest
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Northwest
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450867
Entity Address
11113 RESEARCH BLVD
AUSTIN, TX 78759-5297
Medicare Provider Number
450867
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
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
8/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tony DeDominico, COO
(512) 324-6046
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/15/2021
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