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OPTUM PHARMACY 702, LLC
DSH250117 HIGHLAND COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
HIGHLAND COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250117
Entity Address
130 Highland Parkway
PICAYUNE, MS 39466
Medicare Provider Number
250117
Participating Start Date
10/1/2007
Last Recertification Date
8/15/2024
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
Bryan Keith Maxie, Regional Administrator
(601) 297-0503
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/14/2022
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