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GENOA HEALTHCARE LLC
DSH220086 BETH ISRAEL DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
BETH ISRAEL DEACONESS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220086
Entity Address
330 Brookline Ave
BOSTON, MA 02215
Medicare Provider Number
220086
Participating Start Date
10/1/2009
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
173 OXFORD ST
LOWER LEVEL - SUITE P
LYNN, MA 01901
Pharmacy Comments
Contract Details
Approval Date
4/22/2021
Contract Begin Date
4/23/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Cullen, CFO
(617) 667-7146
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/22/2021
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