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OPTUM PHARMACY 702, LLC
CAH181316-00 ARH MARY BRECKINRIDGE HEALTH SERVICES, INC. DBA MARY BRECKINRIDGE ARH HOSPITAL
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Covered Entity Details
Entity Name
ARH MARY BRECKINRIDGE HEALTH SERVICES, INC. DBA MARY BRECKINRIDGE ARH HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181316-00
Entity Address
130 KATE IRELAND DRIVE
HYDEN, KY 41749
Medicare Provider Number
181316
Participating Start Date
10/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/31/2023
Contract Begin Date
6/5/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Maria Braman, Chief Medical Officer
(406) 465-8506
Contract Pharmacy Representative
Optum
Patti Schnieder, 340B ACE
(402) 802-5169
Signed By Date
5/31/2023
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