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OPTUM PHARMACY 702, LLC
DSH140304 UChicago Medicine AdventHealth Bolingbrook
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Covered Entity Details
Entity Name
UChicago Medicine AdventHealth Bolingbrook
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140304
Entity Address
500 REMINGTON BLVD.
BOLINGBROOK, IL 60440-4988
Medicare Provider Number
140304
Participating Start Date
10/1/2009
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vladimir Radivojevic, President & CEO
(630) 545-7258
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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