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OPTUM PHARMACY 702, LLC
DSH330024 THE MOUNT SINAI HOSPITAL
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Covered Entity Details
Entity Name
THE MOUNT SINAI HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330024
Entity Address
ONE GUSTAVE L. LEVY PLACE
NEW YORK, NY 10029
Medicare Provider Number
330024
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Pastier, Senior VP/CFO - The Mount Sinai Hospital
(212) 731-3149
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/11/2019
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