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OPTUM INFUSION SERVICES 302, LLC
DSH260011 SSM HEALTH-ST. MARYS-JEFFERSON CITY
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Covered Entity Details
Entity Name
SSM HEALTH-ST. MARYS-JEFFERSON CITY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260011
Entity Address
2505 Mission Drive
JEFFERSON CITY, MO 65109
Medicare Provider Number
260011
Participating Start Date
7/1/2022
Last Recertification Date
9/1/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 302, LLC
Pharmacy Address
8720 S 114TH ST STE 106
LA VISTA, NE 68128-5585
Pharmacy Comments
Contract Details
Approval Date
4/13/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Becky Miller, Vice President-Hospital Operations
(573) 681-3136
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/13/2021
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