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OPTUM INFUSION SERVICES 500, INC
DSH030014 HONORHEALTH JOHN C. LINCOLN MED CTR
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Covered Entity Details
Entity Name
HONORHEALTH JOHN C. LINCOLN MED CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030014
Entity Address
250 E Dunlap Ave
Phoenix, AZ 85020
Medicare Provider Number
030014
Participating Start Date
7/1/2015
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 500, INC
Pharmacy Address
5627 UNIVERSITY HTS STE 105
SAN ANTONIO, TX 78249-3583
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/14/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Gary Baker, SVP-CEO-HOSPITAL
(480) 583-0803
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2022
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