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OPTUM PHARMACY 702, LLC
SCH370089-00 NORTHEASTERN HEALTH SYSTEM
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Covered Entity Details
Entity Name
NORTHEASTERN HEALTH SYSTEM
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370089-00
Entity Address
1400 E. DOWNING
TAHLEQUAH, OK 74464
Medicare Provider Number
370089
Participating Start Date
4/1/2018
Last Recertification Date
9/8/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/18/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/18/2022
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