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OPTUM INFUSION SERVICES 305, LLC
DSH330195 LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330195
Entity Address
270-05 76TH AVENUE
NEW HYDE PARK, NY 11040
Medicare Provider Number
330195
Participating Start Date
7/1/2007
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 305, LLC
Pharmacy Address
4000 CHEMICAL RD STE 100
PLYMOUTH MEETING, PA 19462
Pharmacy Comments
Contract Details
Approval Date
10/12/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/12/2021
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