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OPTUM INFUSION SERVICES 203 INC
DSH360077 FAIRVIEW HOSPITAL
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Covered Entity Details
Entity Name
FAIRVIEW HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360077
Entity Address
18101 LORAIN AVE
CLEVELAND, OH 44111
Medicare Provider Number
360077
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 203 INC
Pharmacy Address
9984 PREMIER PKWY
MIRAMAR, FL 33025-3209
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Neil P. Smith, President - Fairview Hospital
(216) 476-4499
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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