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OPTUM PHARMACY 702, LLC
DSH330221 WYCKOFF HEIGHTS MEDICAL CENTER
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Covered Entity Details
Entity Name
WYCKOFF HEIGHTS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330221
Entity Address
374 STOCKHOLM STREET
BROOKLYN, NY 11237
Medicare Provider Number
330221
Participating Start Date
10/4/2019
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ramon Rodriguez, President and CEO
(718) 963-7101
Contract Pharmacy Representative
Wyckoff Heights Medical Center
Joseph S Rumore, Director of Pharmacy
(718) 963-7547 Ext: 7141
Signed By Date
7/15/2020
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