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OPTUM PHARMACY 806, INC.
DSH140182 ADVOCATE NORTH SIDE HEALTH NETWORK
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Covered Entity Details
Entity Name
ADVOCATE NORTH SIDE HEALTH NETWORK
Subdivision Name
DBA ADVOCATE ILLINOIS MASONIC MEDICAL CENTER (AIMMC)
Type
Disproportionate Share Hospital
340B ID
DSH140182
Entity Address
836 West Wellington Ave.
CHICAGO, IL 60657
Medicare Provider Number
140182
Participating Start Date
10/27/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 806, INC.
Pharmacy Address
2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/15/2021
Business decision by covered entity and/or pharmacy
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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