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OPTUM PHARMACY 702, LLC
DSH310084 Monmouth Medical Center Southern Campus
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Covered Entity Details
Entity Name
Monmouth Medical Center Southern Campus
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH310084
Entity Address
600 RIVER AVE
LAKEWOOD, NJ 08701
Medicare Provider Number
310084
Participating Start Date
1/1/2015
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/18/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cory Lasker, V.P. Financial Services
(732) 923-6289
Contract Pharmacy Representative
Optum
Jeff Noone, National Account Manager
(412) 973-2453
Signed By Date
4/18/2022
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