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OPTUM PHARMACY 701, LLC
DSH220086 BETH ISRAEL DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
BETH ISRAEL DEACONESS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220086
Entity Address
330 Brookline Ave
BOSTON, MA 02215
Medicare Provider Number
220086
Participating Start Date
10/1/2009
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
1/30/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Larkin, Chief Operating Officer
(617) 677-7144
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/30/2025
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