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OPTUM PHARMACY 702, LLC
DSH190044 ACADIA GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ACADIA GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190044
Entity Address
1305 CROWLEY RAYNE HWY.
CROWLEY, LA 70526
Medicare Provider Number
190044
Participating Start Date
4/1/2011
Last Recertification Date
8/27/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/16/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Joseph James Mitchell, CEO
(337) 788-6400
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/16/2021
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