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OPTUM PHARMACY 702, LLC
DSH330219 ERIE COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
ERIE COUNTY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330219
Entity Address
462 Grider Street
BUFFALO, NY 14215
Medicare Provider Number
330219
Participating Start Date
4/1/1996
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jonathan Thomas Swiatkowski, Chief Financial Officer
(716) 898-6291
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/17/2023
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