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OPTUM PHARMACY 702, LLC
DSH360008 SOUTHERN OHIO MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHERN OHIO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360008
Entity Address
1805 27TH STREET
PORTSMOUTH, OH 45662
Medicare Provider Number
360008
Participating Start Date
4/1/2005
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
5/17/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kara Plummer, Associate CFO, Administration
(740) 356-8880
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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