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OPTUM PHARMACY 702, LLC
DSH140133 HOLY CROSS HOSPITAL
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Covered Entity Details
Entity Name
HOLY CROSS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140133
Entity Address
2701 WEST 68TH STREET
CHICAGO, IL 60629
Medicare Provider Number
140133
Participating Start Date
7/1/2005
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Loren Chandler, EVP COO
(773) 257-5658
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/11/2018
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