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OPTUM PHARMACY 701, LLC
DSH140155 Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140155
Entity Address
500 West Court Street
Kankakee, IL 60901
Medicare Provider Number
140155
Participating Start Date
10/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
4/2/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sylvia Chen, Regional VP - Pharmacy Services
(630) 776-3455
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/2/2025
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