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OPTUM PHARMACY 702, LLC
DSH070006 THE STAMFORD HOSPITAL
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Covered Entity Details
Entity Name
THE STAMFORD HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070006
Entity Address
One Hospital Plaza
STAMFORD, CT 06902
Medicare Provider Number
070006
Participating Start Date
7/1/2016
Last Recertification Date
8/23/2024
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
Ellen Komar, CNO & Sr VP -Patient Services
(203) 276-7401 Ext: 7401
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
7/15/2019
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