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DIPLOMAT SPECIALTY PHARMACY
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
4100 S SAGINAW ST
STE D
FLINT, MI 48507-2683
Pharmacy Comments
04/09/2012 update address and name (added suite)
Contract Details
Approval Date
7/17/2020
Contract Begin Date
8/28/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/17/2023
Ownership change
Contacts
Covered Entity Signing Official
Michele Mazurek, Hospital Chief Administator
(773) 257-5021
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/17/2020
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