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OPTUM PHARMACY 702, LLC
DSH140224 PRESENCE SAINT JOSEPH HOSP-CHICAGO
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Covered Entity Details
Entity Name
PRESENCE SAINT JOSEPH HOSP-CHICAGO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140224
Entity Address
2900 NORTH LAKE SHORE DRIVE
CHICAGO, IL 60657
Medicare Provider Number
140224
Participating Start Date
7/1/2021
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/17/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Flavio Marin, CFO
(847) 316-4190
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/17/2021
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