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OPTUM PHARMACY 702, LLC
CAH261307-00 GENERAL JOHN J. PERSHING MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GENERAL JOHN J. PERSHING MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261307-00
Entity Address
130 E. LOCKLING AVENUE
BROOKFIELD, MO 64628
Medicare Provider Number
261307
Participating Start Date
4/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Karla Clubine, CEO
(660) 258-1141
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/17/2023
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