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OPTUM PHARMACY 702, LLC
DSH330044 MVHS, Inc. DBA: Wynn Hospital
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Covered Entity Details
Entity Name
MVHS, Inc. DBA: Wynn Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330044
Entity Address
111 Hospital Drive
Utica, NY 13502
Medicare Provider Number
330044
Participating Start Date
7/1/2014
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/7/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Louis Aiello, Sr. VP Finance/ CFO
(315) 917-8213
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/7/2022
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