Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
DSH330127 JACOBI MEDICAL CENTER (NYCHHC)

Covered Entity Details

Entity Name

JACOBI MEDICAL CENTER (NYCHHC)

Subdivision Name

FORMERLY BRONX MUNICIPAL HOSPITAL

Type

Disproportionate Share Hospital

340B ID

DSH330127

Entity Address

1400 PELHAM PKWY SOUTH
BRONX, NY 10461

Medicare Provider Number

330127

Participating Start Date

12/1/1992

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

10/17/2022

Contract Begin Date

1/1/2023

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Deborah Alyse Brown, Senior Vice President, Chief External Affairs Officer
(347) 947-0446

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

10/17/2022

340B Drug Pricing Program Database