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OPTUM PHARMACY 701, LLC
DSH390133 LEHIGH VALLEY
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Covered Entity Details
Entity Name
LEHIGH VALLEY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390133
Entity Address
1200 South Cedar Crest Boulevard
ALLENTOWN, PA 18103-4000
Medicare Provider Number
390133
Participating Start Date
1/1/2023
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/11/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Thomas Marchozzi, Executive Vice President & Chief Financial Officer
(484) 862-3943
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/11/2024
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