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OPTUM INFUSION SERVICES 500, INC.
DSH230165 Ascension St. John Hospital DBA Henry Ford St. John Hospital
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Covered Entity Details
Entity Name
Ascension St. John Hospital DBA Henry Ford St. John Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230165
Entity Address
22101 MOROSS ROAD
DETROIT, MI 48236
Medicare Provider Number
230165
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
OPTUM INFUSION SERVICES 500, INC.
Pharmacy Address
2685 PATTON RD
ROSEVILLE, MN 55113
Pharmacy Comments
Contract Details
Approval Date
10/22/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doug Clark, SVP - Corporate Finance
(313) 874-5446
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/22/2024
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