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OPTUM PHARMACY 702, LLC
DSH330198 Mount Sinai South Nassau
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Covered Entity Details
Entity Name
Mount Sinai South Nassau
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330198
Entity Address
ONE HEALTHY WAY
OCEANSIDE, NY 11572
Medicare Provider Number
330198
Participating Start Date
10/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
8/13/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Pastier, Senior VP/CFO - The Mount Sinai Hospital
(212) 731-3149
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/12/2024
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