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OPTUM PHARMACY 701, LLC
DSH070028 ST. VINCENTS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. VINCENTS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH070028
Entity Address
2800 MAIN STREET
BRIDGEPORT, CT 06606-4201
Medicare Provider Number
070028
Participating Start Date
1/13/2023
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/17/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Christopher Given, VP, Finance
(475) 210-6193
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/17/2025
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