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OPTUM PHARMACY 705, LLC
DSH330046 MOUNT SINAI WEST
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Covered Entity Details
Entity Name
MOUNT SINAI WEST
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330046
Entity Address
1000 TENTH AVENUE
NEW YORK, NY 10019
Medicare Provider Number
330046
Participating Start Date
7/1/2005
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
Pharmacy Comments
Contract Details
Approval Date
10/7/2024
Contract Begin Date
1/1/2025
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
10/7/2024
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