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OPTUM PHARMACY 702, LLC
DSH140158 Insight Hospital and Medical Center Chicago
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Covered Entity Details
Entity Name
Insight Hospital and Medical Center Chicago
Subdivision Name
MAIN SITE
Type
Disproportionate Share Hospital
340B ID
DSH140158
Entity Address
2525 S. MICHIGAN AVENUE
CHICAGO, IL 60616
Medicare Provider Number
140158
Participating Start Date
7/1/2004
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Baseer Tajuddin, General Counsel
(217) 377-6978
Contract Pharmacy Representative
Optum
Nancy McCutcheon, Sr. VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2022
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