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OPTUM PHARMACY 701, LLC
DSH450021 BAYLOR UNIVERSITY MEDICAL CTR
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Covered Entity Details
Entity Name
BAYLOR UNIVERSITY MEDICAL CTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450021
Entity Address
3500 GASTON AVENUE
DALLAS, TX 75246
Medicare Provider Number
450021
Participating Start Date
3/7/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/12/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kyle Armstrong, President
(214) 820-3101
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/12/2023
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