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OPTUM PHARMACY 701, LLC
DSH330119 LENOX HILL HOSPITAL
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Covered Entity Details
Entity Name
LENOX HILL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330119
Entity Address
100 EAST 77TH STREET
NEW YORK, NY 10075
Medicare Provider Number
330119
Participating Start Date
1/24/2022
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/3/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/3/2024
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