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OPTUM PHARMACY 702, LLC
DSH010125 LAKELAND COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
LAKELAND COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010125
Entity Address
42024 HIGHWAY 195 EAST
HALEYVILLE, AL 35565
Medicare Provider Number
010125
Participating Start Date
4/1/2020
Last Recertification Date
8/16/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/9/2021
Contract Begin Date
5/5/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ashley Pool, Chief Executive Officer
(205) 485-7108
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/9/2021
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