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OPTUM PHARMACY 702, LLC
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
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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