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OPTUM PHARMACY 706, INC.
PED033302-00 PHOENIX CHILDREN'S HOSPITAL
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Covered Entity Details
Entity Name
PHOENIX CHILDREN'S HOSPITAL
Subdivision Name
Type
Children's Hospital
340B ID
PED033302-00
Entity Address
1919 E THOMAS ROAD
PHOENIX, AZ 85016
Medicare Provider Number
033302
Participating Start Date
4/1/2010
Last Recertification Date
9/19/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
7/16/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/9/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Douglas T Myers, CFO
(602) 933-1393
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/16/2018
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