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OPTUM PHARMACY 702, LLC
CAH171356-00 ST. LUKE HOSPITAL
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Covered Entity Details
Entity Name
ST. LUKE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171356-00
Entity Address
535 SOUTH FREEBORN
MARION, KS 66861
Medicare Provider Number
171356
Participating Start Date
7/1/2015
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/19/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeremy Ensey, CEO
(620) 382-2177 Ext: 111
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
5/19/2023
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