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OPTUM PHARMACY 702, LLC
DSH330233 BROOKDALE HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BROOKDALE HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330233
Entity Address
ONE BROOKDALE PLAZA
BROOKLYN, NY 11212
Medicare Provider Number
330233
Participating Start Date
10/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/19/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Porter, CFO
(718) 240-5773
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
7/19/2018
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