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OPTUM PHARMACY 702, LLC
DSH190118 DESOTO REGIONAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
DESOTO REGIONAL HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190118
Entity Address
207 JEFFERSON STREET
MANSFIELD, LA 71052
Medicare Provider Number
190118
Participating Start Date
7/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TODD EPPLER, CEO
(318) 871-3132
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/14/2022
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