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OPTUM PHARMACY 702, LLC
DSH360218 LICKING MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LICKING MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360218
Entity Address
1320 WEST MAIN STREET
NEWARK, OH 43055
Medicare Provider Number
360218
Participating Start Date
12/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
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
Cynthia L. Webster, Chief Financial Officer
(220) 564-4518
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2024
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