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OPTUM PHARMACY 702, LLC
DSH440048 BAPTIST MEM HOSPITAL MEMPHIS
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Covered Entity Details
Entity Name
BAPTIST MEM HOSPITAL MEMPHIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440048
Entity Address
6019 WALNUT GROVE ROAD
MEMPHIS, TN 38120
Medicare Provider Number
440048
Participating Start Date
7/1/2017
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
Contract Termination Date
Termination Reason
1/1/2022
Business decision by covered entity and/or pharmacy
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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