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OPTUM PHARMACY 702, LLC
CAH251304-00 TALLAHATCHIE GENERAL HOSPITAL
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Covered Entity Details
Entity Name
TALLAHATCHIE GENERAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH251304-00
Entity Address
141 Dr. T.T. Lewis Circle
CHARLESTON, MS 38921
Medicare Provider Number
251304
Participating Start Date
4/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/17/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James D. Blackwood, CEO
(662) 625-5535
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/17/2022
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