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OPTUM PHARMACY 702, LLC
DSH260070 PEMISCOT COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PEMISCOT COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260070
Entity Address
946 East Reed
HAYTI, MO 63851
Medicare Provider Number
260070
Participating Start Date
1/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leigha Kristen Ward, Chief Financial Officer
(573) 359-3612
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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