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OPTUM PHARMACY 702, LLC
RRC100307-00 ST. VINCENTS MEDICAL CENTER SOUTHSID
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Covered Entity Details
Entity Name
ST. VINCENTS MEDICAL CENTER SOUTHSID
Subdivision Name
Type
Rural Referral Center
340B ID
RRC100307-00
Entity Address
4201 BELFORT ROAD
JACKSONVILLE, FL 32216
Medicare Provider Number
100307
Participating Start Date
10/1/2020
Last Recertification Date
8/20/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/10/2023
Contract Begin Date
5/10/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Susan Cornejo, Chief Operating Officer
(850) 416-6206
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
5/10/2023
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