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OPTUM PHARMACY 702, LLC
RRC150082-00 DEACONESS HOSPITAL
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Covered Entity Details
Entity Name
DEACONESS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC150082-00
Entity Address
600 MARY STREET
EVANSVILLE, IN 47747
Medicare Provider Number
150082
Participating Start Date
10/20/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/20/2021
Contract Begin Date
10/20/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cheryl Wathen, Chief Financial Officer
(812) 450-3296
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/12/2021
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