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OPTUM PHARMACY 702, LLC
DSH440059 COOKEVILLE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COOKEVILLE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440059
Entity Address
Cookeville Regional Medical Center
1 Medical Center Blvd
COOKEVILLE, TN 38501
Medicare Provider Number
440059
Participating Start Date
4/1/2023
Last Recertification Date
8/22/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
2/14/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
PAUL Dudley KORTH, CEO
(931) 783-2000
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/16/2023
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