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OPTUM PHARMACY 702, LLC
RRC250141-00 BAPTIST MEM HOSPITAL DESOTO
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Covered Entity Details
Entity Name
BAPTIST MEM HOSPITAL DESOTO
Subdivision Name
Type
Rural Referral Center
340B ID
RRC250141-00
Entity Address
7601 SOUTHCREST
SOUTHAVEN, MS 38671
Medicare Provider Number
250141
Participating Start Date
11/12/2020
Last Recertification Date
8/28/2024
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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