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OPTUM PHARMACY 702, LLC
DSH200001 ST JOSEPH HOSPITAL
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Covered Entity Details
Entity Name
ST JOSEPH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200001
Entity Address
360 BROADWAY
BANGOR, ME 04401
Medicare Provider Number
200001
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/10/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Allan Hendrix, Vice of President of Finance
(207) 907-1600
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/10/2025
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