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OPTUM PHARMACY 702, LLC
DSH140208 ADVOCATE CHRIST MEDICAL CENTER
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Covered Entity Details
Entity Name
ADVOCATE CHRIST MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140208
Entity Address
4440 W 95TH ST
OAK LAWN, IL 60453
Medicare Provider Number
140208
Participating Start Date
7/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nanine Nelson, SVP-Finance
(414) 299-1610
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/13/2020
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