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OPTUM PHARMACY 701, LLC
DSH450032 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450032
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450032
Participating Start Date
7/1/2022
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/4/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Cheek, CFO
(903) 315-1814
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
10/4/2024
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