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OPTUM PHARMACY 702, LLC
RRC250100-00 BAPTIST MEM HOSPITAL GOLDEN TRIANGLE
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Covered Entity Details
Entity Name
BAPTIST MEM HOSPITAL GOLDEN TRIANGLE
Subdivision Name
Type
Rural Referral Center
340B ID
RRC250100-00
Entity Address
2520 FIFTH STREET NORTH
COLUMBUS, MS 39701
Medicare Provider Number
250100
Participating Start Date
4/1/2022
Last Recertification Date
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
2/1/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kimberly Young, Vice President-Finance Operations
(901) 227-4080
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/13/2022
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