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OPTUM PHARMACY 702, LLC
SCH260006-00 HEARTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HEARTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260006-00
Entity Address
5325 FARAON
ST. JOSEPH, MO 64506-3398
Medicare Provider Number
260006
Participating Start Date
10/1/2020
Last Recertification Date
8/30/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dwain Stilson, Chief Financial Officer
(816) 271-7070
Contract Pharmacy Representative
Briova
Joseph L Lovino, Manager, 340B Specialty Program
(412) 445-4495
Signed By Date
4/16/2018
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