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OPTUM PHARMACY 702, LLC
CAH141305-00 Memorial Hospital Association
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Covered Entity Details
Entity Name
Memorial Hospital Association
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141305-00
Entity Address
1454 North Co Road 2050 East
Carthage, IL 62321
Medicare Provider Number
141305
Participating Start Date
1/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Teresa Smith, CFO
(217) 357-8573
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/15/2025
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