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OPTUM PHARMACY 702, LLC
DSH140181 SOUTH SHORE HOSPITAL CORPORATION
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Covered Entity Details
Entity Name
SOUTH SHORE HOSPITAL CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140181
Entity Address
8012 SOUTH CRANDON AVENUE
CHICAGO, IL 60617-1175
Medicare Provider Number
140181
Participating Start Date
4/1/2022
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/7/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leslie M. Rogers, CEO
(773) 356-5200
Contract Pharmacy Representative
Avella/BriovaRx
Paul Leschinert, National Account Manager,340B Sales
(847) 409-0200
Signed By Date
7/7/2022
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