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OPTUM PHARMACY 702, LLC
DSH040118 NEA BAPTIST MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
NEA BAPTIST MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040118
Entity Address
4800 EAST JOHNSON AVENUE
JONESBORO, AR 72405
Medicare Provider Number
040118
Participating Start Date
4/28/2020
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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