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OPTUM PHARMACY 801, INC.
DSH330241 UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330241
Entity Address
750 East Adams Street
Syracuse, NY 13210
Medicare Provider Number
330241
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 801, INC.
Pharmacy Address
24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085
Pharmacy Comments
Contract Details
Approval Date
10/4/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert John Corona, CEO
(315) 464-4223
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/4/2020
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