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OPTUM PHARMACY 702, LLC
DSH190060 Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
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Covered Entity Details
Entity Name
Southwest Louisiana Hospital Association d/b/a Lake Charles Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190060
Entity Address
1701 OAK PARK BOULEVARD
LAKE CHARLES, LA 70601
Medicare Provider Number
190060
Participating Start Date
1/1/2005
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
8/12/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Devon Hyde, President/CEO
(337) 494-3200
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/7/2022
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