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OPTUM PHARMACY 702, LLC
DSH010024 JACKSON HOSPITAL AND CLINIC INC
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Covered Entity Details
Entity Name
JACKSON HOSPITAL AND CLINIC INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010024
Entity Address
1725 PINE STREET
MONTGOMERY, AL 36106-1109
Medicare Provider Number
010024
Participating Start Date
9/7/2022
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
9/9/2022
Contract Begin Date
9/12/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joe Riley, CEO
(334) 293-8809
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
9/9/2022
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