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OPTUM PHARMACY 702, LLC
CAH281359-00 MEMORIAL COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
MEMORIAL COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281359-00
Entity Address
810 N. 22ND ST
BLAIR, NE 68008
Medicare Provider Number
281359
Participating Start Date
1/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/3/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/22/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JENNIFER NEWBY, Operations Director, Finance and Support Services
(402) 426-1295
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/3/2023
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