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OPTUM PHARMACY 702, LLC
DSH140054 MACNEAL HOSPITAL
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Covered Entity Details
Entity Name
MACNEAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140054
Entity Address
3249 SOUTH OAK PARK AVENUE
BERWYN, IL 60402
Medicare Provider Number
140054
Participating Start Date
1/1/2019
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/28/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/2/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/28/2020
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