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OPTUM INFUSION SERVICES 402, LLC
DSH450137 BAYLOR SCOTT & WHITE ALL SAINTS MEDICAL CENTER - FORT WORTH
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Covered Entity Details
Entity Name
BAYLOR SCOTT & WHITE ALL SAINTS MEDICAL CENTER - FORT WORTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450137
Entity Address
1400 8TH AVENUE
FORT WORTH, TX 76104
Medicare Provider Number
450137
Participating Start Date
1/1/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 402, LLC
Pharmacy Address
2300 MAIN ST STE 150
IRVINE, CA 92614-6223
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/16/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Lucy Catala, VP CFO - DFW West Region
(817) 922-1957
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/12/2024
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