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OPTUM PHARMACY 702, LLC
DSH330395 EPISCOPAL HEALTH SERVICES INC
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Covered Entity Details
Entity Name
EPISCOPAL HEALTH SERVICES INC
Subdivision Name
ST JOHN'S EPISCOPAL HOSPITAL - SOUTH SHORE
Type
Disproportionate Share Hospital
340B ID
DSH330395
Entity Address
327 BEACH 19TH STREET
FAR ROCKAWAY, NY 11691
Medicare Provider Number
330395
Participating Start Date
12/15/2005
Last Recertification Date
9/17/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2020
Contract Begin Date
10/23/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gerard M. Walsh, CEO
(718) 869-7320
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2020
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