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OPTUM PHARMACY 702, LLC
RRC330106-00 NORTH SHORE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
NORTH SHORE UNIVERSITY HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330106-00
Entity Address
300 COMMUNITY DRIVE
MANHASSET, NY 11030
Medicare Provider Number
330106
Participating Start Date
10/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
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
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/18/2024
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