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OPTUM PHARMACY 702, LLC
DSH330180 SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330180
Entity Address
2215 BURDETT AVE
TROY, NY 12180
Medicare Provider Number
330180
Participating Start Date
1/1/2019
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/10/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/24/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Santos, CFO
(518) 525-5537
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/10/2020
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