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OPTUM PHARMACY 701, LLC
DSH140083 LORETTO HOSPITAL
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Covered Entity Details
Entity Name
LORETTO HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140083
Entity Address
645 SOUTH CENTRAL
CHICAGO, IL 60644
Medicare Provider Number
140083
Participating Start Date
12/6/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
5/4/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/14/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Morales, Interim CFO
(773) 854-5438
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
5/4/2023
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