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OPTUM PHARMACY 702, LLC
DSH220033AG BEVERLY HOSPITAL
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Covered Entity Details
Entity Name
BEVERLY HOSPITAL
Subdivision Name
LAHEY OUTPATIENT CENTER DANVERS / DAN VASCULAR LAB
Type
Disproportionate Share Hospital
340B ID
DSH220033AG
Entity Address
480 maple street
Suite 105
Danvers, MA 01923
Medicare Provider Number
220033
Outpatient Facility Provider Number
Participating Start Date
10/1/2017
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/18/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tom Sands, President
(978) 816-2580
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/18/2023
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