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OPTUM PHARMACY 702, LLC
DSH180138 Baptist Health Lagrange
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Covered Entity Details
Entity Name
Baptist Health Lagrange
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180138
Entity Address
1025 New Moody Lane
La Grange, KY 40031
Medicare Provider Number
180138
Participating Start Date
7/1/2013
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
1/21/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Clint Kaho, President
(502) 222-3329
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
1/21/2022
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