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OPTUM PHARMACY 702, LLC
DSH330307 CAYUGA MEDICAL CENTER AT ITHACA
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Covered Entity Details
Entity Name
CAYUGA MEDICAL CENTER AT ITHACA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330307
Entity Address
101 DATES DRIVE
ITHACA, NY 14850
Medicare Provider Number
330307
Participating Start Date
7/1/2019
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/16/2023
Contract Begin Date
2/28/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Collett, CHIEF FINANCIAL OFFICER
(607) 274-4441
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/16/2023
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