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OPTUM PHARMACY 702, LLC
DSH180104 BAPTIST HEALTH PADUCAH
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Covered Entity Details
Entity Name
BAPTIST HEALTH PADUCAH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180104
Entity Address
2501 KENTUCKY AVENUE
PADUCAH, KY 42003
Medicare Provider Number
180104
Participating Start Date
4/1/2016
Last Recertification Date
8/30/2024
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
5/17/2023
Contract Begin Date
5/23/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kenneth Boyd, President
(270) 575-2101
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
5/17/2023
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