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OPTUM PHARMACY 702, LLC
DSH450346 BAPTIST HOSPITALS OF SOUTHEAST TEXAS DBA BAPTIST BEAUMONT HOSPITAL
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Covered Entity Details
Entity Name
BAPTIST HOSPITALS OF SOUTHEAST TEXAS DBA BAPTIST BEAUMONT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450346
Entity Address
3080 COLLEGE STREET
BEAUMONT, TX 77701
Medicare Provider Number
450346
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/4/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gary Troutman, Chief Financial Officer
(409) 212-5003
Contract Pharmacy Representative
Baptist Hospitals of Southeast Texas
Aily Powell, Administrative Director of Pharmacy
(409) 212-7282
Signed By Date
4/4/2022
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