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OPTUM PHARMACY 706, INC.
DSH210058 JAMES LAWRENCE KERNAN HOSPITAL
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Covered Entity Details
Entity Name
JAMES LAWRENCE KERNAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210058
Entity Address
2200 KERNAN DRIVE
BALTIMORE, MD 21207
Medicare Provider Number
210058
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Julie Ann Nemens, Senior Vice President/Chief Administrative Officer
(410) 448-6741
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2023
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