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OPTUM PHARMACY 702, LLC
DSH450801 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450801
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
4/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
8/1/2024
Contract Begin Date
8/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Adams, President
(903) 614-2001
Contract Pharmacy Representative
Optum
Shehan Welihindha, National Account Manager
(916) 233-7775
Signed By Date
8/1/2024
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