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OPTUM PHARMACY 702, LLC
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/13/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Post, Executive Vice President
(708) 216-1670
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
1/13/2019
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