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OPTUM PHARMACY 702, LLC
DSH390027 TEMPLE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
TEMPLE UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390027
Entity Address
3401 North Broad Street
PHILADELPHIA, PA 19140
Medicare Provider Number
390027
Participating Start Date
1/1/2004
Last Recertification Date
8/17/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tony Reed, Chief Medical Officer
(215) 707-5880
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2021
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