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OPTUM PHARMACY 702, LLC
PED453306-00 Methodist Children's Hospital d/b/a Covenant Children's Hospital
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Covered Entity Details
Entity Name
Methodist Children's Hospital d/b/a Covenant Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453306-00
Entity Address
4015 22nd Place
Lubbock, TX 79410
Medicare Provider Number
453306
Participating Start Date
1/1/2018
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/18/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Grigson, CFO
(806) 725-0598
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/18/2021
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