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OPTUM PHARMACY 702, LLC
DSH190041 CHRISTUS Shreveport-Bossier Health System
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Covered Entity Details
Entity Name
CHRISTUS Shreveport-Bossier Health System
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190041
Entity Address
1453 E. Bert Kouns Industrial Loop
Shreveport, LA 71105
Medicare Provider Number
190041
Participating Start Date
7/1/2024
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/29/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Glen Boles, VP & Chief Financial Officer
(903) 614-2007
Contract Pharmacy Representative
Optum
Shehan Welihindha, National Account Manager
(916) 233-7775
Signed By Date
4/12/2024
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