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OPTUM PHARMACY 702, LLC
RRC330119-00 LENOX HILL HOSPITAL
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Covered Entity Details
Entity Name
LENOX HILL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330119-00
Entity Address
100 EAST 77TH STREET
NEW YORK, NY 10075
Medicare Provider Number
330119
Participating Start Date
7/1/2017
Last Recertification Date
9/15/2021
Entity Termination Date
1/24/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2022
Covered Entity Terminated
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
10/15/2020
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