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OPTUM PHARMACY 702, LLC
PED453301-00 Driscoll Children's Hospital
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Covered Entity Details
Entity Name
Driscoll Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453301-00
Entity Address
3533 South Alameda St
Corpus Christi, TX 78411
Medicare Provider Number
453301
Participating Start Date
10/1/2011
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven Eric King, CFO
(361) 694-5934
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2021
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