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OPTUM PHARMACY 702, LLC
DSH310002 NEWARK BETH ISRAEL MEDICAL CENTER
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Covered Entity Details
Entity Name
NEWARK BETH ISRAEL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310002
Entity Address
201 LYONS AVENUE
NEWARK, NJ 07112
Medicare Provider Number
310002
Participating Start Date
10/1/2004
Last Recertification Date
8/21/2024
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
Douglas Zehner, Senior Vice President
(973) 926-6982
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/15/2019
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