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OPTUM PHARMACY 701, LLC
DSH450079 BAYLOR MEDICAL CENTER AT IRVING
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Covered Entity Details
Entity Name
BAYLOR MEDICAL CENTER AT IRVING
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450079
Entity Address
1901 NORTH MACARTHUR BLVD
IRVING, TX 75061
Medicare Provider Number
450079
Participating Start Date
7/1/2019
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CINDY K. SCHAMP, PRESIDENT
(972) 990-8102
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/12/2024
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