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OPTUM PHARMACY 702, LLC
DSH190116 MOREHOUSE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
MOREHOUSE GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190116
Entity Address
323 WEST WALNUT
BASTROP, LA 71220
Medicare Provider Number
190116
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Derrick Frazier, Chief Executive Officer
(318) 283-3601
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/12/2021
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