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OPTUM PHARMACY 702, LLC
DSH140088 THE UNIVERSITY OF CHICAGO MEDICAL CENTER
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Covered Entity Details
Entity Name
THE UNIVERSITY OF CHICAGO MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140088
Entity Address
5841 S. MARYLAND AVE.
CHICAGO, IL 60637
Medicare Provider Number
140088
Participating Start Date
10/1/2003
Last Recertification Date
8/29/2024
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
Richard Walter Silveria, EVP and CFO
(773) 834-2802
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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