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OPTUM PHARMACY 702, LLC
RRC180035-00 ST ELIZABETH HEALTHCARE
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Covered Entity Details
Entity Name
ST ELIZABETH HEALTHCARE
Subdivision Name
Type
Rural Referral Center
340B ID
RRC180035-00
Entity Address
1 MEDICAL VILLAGE DRIVE
EDGEWOOD, KY 41017-3403
Medicare Provider Number
180035
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
2/27/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lori Ritchey-Baldwin, CFO
(859) 655-1642
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/12/2024
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