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OPTUM PHARMACY 702, LLC
RRC190041-00 CHRISTUS Shreveport-Bossier Health System
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Covered Entity Details
Entity Name
CHRISTUS Shreveport-Bossier Health System
Subdivision Name
Type
Rural Referral Center
340B ID
RRC190041-00
Entity Address
1453 E. Bert Kouns Industrial Loop
Shreveport, LA 71105
Medicare Provider Number
190041
Participating Start Date
1/1/2025
Last Recertification Date
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/29/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Glen Boles, VP & Chief Financial Officer
(903) 614-2007
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Sr VP of Strategic Sales
(651) 983-0677
Signed By Date
10/7/2024
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