Contract Pharmacy Details

OPTUMRX
DSH330195 LONG ISLAND JEWISH MEDICAL CENTER

Covered Entity Details

Entity Name

LONG ISLAND JEWISH MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330195

Entity Address

270-05 76TH AVENUE
NEW HYDE PARK, NY 11040

Medicare Provider Number

330195

Participating Start Date

7/1/2007

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

OPTUMRX

Pharmacy Address

2858 LOKER AVE E STE 100
CARLSBAD, CA 92010-6608

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

10/6/2022
Pharmacy closed

Contacts

Covered Entity Signing Official

Michele L Cusack, Executive Vice President
(516) 321-6058

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

7/15/2020

340B Drug Pricing Program Database