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OPTUM PHARMACY 700, LLC
DSH190002 LAFAYETTE GENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LAFAYETTE GENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190002
Entity Address
1214 COOLIDGE STREET
LAFAYETTE, LA 70503
Medicare Provider Number
190002
Participating Start Date
10/25/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 700, LLC
Pharmacy Address
5700 DOT COM CT, STE 1000
OVIEDO, FL 32765
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
al jude patin, SVP, Chief Operating Officer
(337) 289-7743
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/11/2021
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