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OPTUM PHARMACY 701, LLC
DSH330153 Ellis Hospital
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Covered Entity Details
Entity Name
Ellis Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330153
Entity Address
1101 Nott Street
Schenectady, NY 12308
Medicare Provider Number
330153
Participating Start Date
7/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
10/18/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marc Mesick, CFO & VP of Finance
(518) 243-4144
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/18/2024
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