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OPTUM PHARMACY 705, LLC
DSH180035 ST ELIZABETH HEALTHCARE
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Covered Entity Details
Entity Name
ST ELIZABETH HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180035
Entity Address
1 MEDICAL VILLAGE DRIVE
EDGEWOOD, KY 41017-3403
Medicare Provider Number
180035
Participating Start Date
10/1/2016
Last Recertification Date
8/20/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
7/3/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lori Ritchey-Baldwin, CFO
(859) 655-1642
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/3/2024
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