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OPTUM PHARMACY 702, LLC
DSH520075 ST.VINCENT HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS
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Covered Entity Details
Entity Name
ST.VINCENT HOSPITAL OF THE HOSPITAL SISTERS OF THE THIRD ORDER OF ST. FRANCIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520075
Entity Address
835 S.VAN BUREN STREET
GREEN BAY, WI 54301
Medicare Provider Number
520075
Participating Start Date
1/1/2010
Last Recertification Date
9/5/2024
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
Contacts
Covered Entity Signing Official
Joanne Horvath, Vice President - Finance
(920) 431-3211
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
4/16/2018
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