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OPTUM PHARMACY 701, LLC
PED393303-00 THE CHILDREN'S HOSPITAL OF PHILADELPHIA
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Covered Entity Details
Entity Name
THE CHILDREN'S HOSPITAL OF PHILADELPHIA
Subdivision Name
Type
Children's Hospital
340B ID
PED393303-00
Entity Address
3401 Civic Center Blvd
PHILADELPHIA, PA 19104
Medicare Provider Number
393303
Participating Start Date
1/1/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jan Pieter Boswinkel, Senior Vice President & Chief Operating Officer, Hospital Operations
(215) 590-3055
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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