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OPTUM PHARMACY 702, LLC
DSH310070 SAINT PETER'S UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SAINT PETER'S UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310070
Entity Address
254 EASTON AVENUE
NEW BRUNSWICK, NJ 08901
Medicare Provider Number
310070
Participating Start Date
1/1/2014
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
10/9/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/14/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Garrick J. Stoldt, Chief Financial Officer
(732) 745-6651
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
10/9/2018
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