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OPTUM PHARMACY 702, LLC
PED193300-00 Children's Hospital
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Covered Entity Details
Entity Name
Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED193300-00
Entity Address
200 HENRY CLAY AVENUE
NEW ORLEANS, LA 70118
Medicare Provider Number
193300
Participating Start Date
1/1/2014
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John R Nickens, President & CEO
(504) 896-9452
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2022
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