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OPTUM PHARMACY 704, INC.
DSH220116 TUFTS MEDICAL CENTER
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Covered Entity Details
Entity Name
TUFTS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220116
Entity Address
800 WASHINGTON STREET
BOSTON, MA 02111
Medicare Provider Number
220116
Participating Start Date
10/1/2003
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
1/12/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kristine Hanscom, CFO
(617) 636-7767
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/12/2022
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