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OPTUM PHARMACY 706, INC.
DSH260078 Ozarks Medical Center DBA Ozarks Healthcare
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Covered Entity Details
Entity Name
Ozarks Medical Center DBA Ozarks Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260078
Entity Address
1100 KENTUCKY AVENUE
WEST PLAINS, MO 65775-1100
Medicare Provider Number
260078
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/5/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Thompson, CFO
(417) 256-9111 Ext: 6031
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/6/2018
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