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OPTUM PHARMACY 702, LLC
DSH070010 BRIDGEPORT HOSPITAL
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Covered Entity Details
Entity Name
BRIDGEPORT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070010
Entity Address
267 GRANT STREET
BRIDGEPORT, CT 06610-0120
Medicare Provider Number
070010
Participating Start Date
4/1/2006
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PATRICK MCCABE, SENIOR VP FINANCE/CFO
(203) 688-2345
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/14/2021
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