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OPTUM PHARMACY 702, LLC
DSH220033 BEVERLY HOSPITAL
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Covered Entity Details
Entity Name
BEVERLY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220033
Entity Address
85 HERRICK STREET
BEVERLY, MA 01915
Medicare Provider Number
220033
Participating Start Date
4/1/2013
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Connie Woodworth, Vice President Finance
(978) 922-3000 Ext: 2587
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/14/2020
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