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OPTUM PHARMACY 705, LLC
DSH440002 JACKSON-MADISON COUNTY GENERAL HOSP
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Covered Entity Details
Entity Name
JACKSON-MADISON COUNTY GENERAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440002
Entity Address
620 SKYLINE DRIVE
JACKSON, TN 38301
Medicare Provider Number
440002
Participating Start Date
7/1/2022
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeff Blankenship, CFO
(731) 541-6739
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2024
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