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OPTUM PHARMACY 705, LLC
DSH450102 CHRISTUS MOTHER FRANCES HOSP-TYLER
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Covered Entity Details
Entity Name
CHRISTUS MOTHER FRANCES HOSP-TYLER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450102
Entity Address
800 EAST DAWSON
TYLER, TX 75701
Medicare Provider Number
450102
Participating Start Date
3/10/2022
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
11142 RENNER BLVD
LENEXA, KS 66219
Pharmacy Comments
Contract Details
Approval Date
3/10/2022
Contract Begin Date
3/10/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/10/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Elizabeth Pulliam, Chief Financial Officer
(903) 606-4102
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
3/1/2022
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