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OPTUM PHARMACY 702, LLC
DSH330160 STATEN ISLAND UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
STATEN ISLAND UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330160
Entity Address
475 SEAVIEW AVE.
STATEN ISLAND, NY 10305
Medicare Provider Number
330160
Participating Start Date
7/1/2004
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/21/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brahim Ardolic, Executive Director
(718) 226-9761
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/21/2021
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