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OPTUM PHARMACY 702, LLC
DSH310075 MONMOUTH MEDICAL CENTER
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Covered Entity Details
Entity Name
MONMOUTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310075
Entity Address
300 SECOND AVENUE
LONG BRANCH, NJ 07740
Medicare Provider Number
310075
Participating Start Date
10/1/2004
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nikolas Alexiades, CFO
(973) 926-7824
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/15/2019
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