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OPTUM PHARMACY 702, LLC
DSH140155 Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140155
Entity Address
500 West Court Street
Kankakee, IL 60901
Medicare Provider Number
140155
Participating Start Date
10/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/21/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Yuesha Chen, Regional Chief Financial Officer
(815) 741-7667
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/21/2021
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