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OPTUM PHARMACY 702, LLC
DSH250100 BAPTIST MEMORIAL HOSPITAL-GOLDEN TRIANGLE
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Covered Entity Details
Entity Name
BAPTIST MEMORIAL HOSPITAL-GOLDEN TRIANGLE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250100
Entity Address
2520 5TH STREET N
COLUMBUS, MS 39705-2008
Medicare Provider Number
250100
Participating Start Date
9/2/2008
Last Recertification Date
8/26/2024
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
Contacts
Covered Entity Signing Official
Kimberly Young, Vice President-Finance Operations
(901) 227-4080
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/16/2021
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