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OPTUM PHARMACY 702, LLC
RRC030092-00 HONORHEALTH DEER VALLEY MED CTR
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Covered Entity Details
Entity Name
HONORHEALTH DEER VALLEY MED CTR
Subdivision Name
Type
Rural Referral Center
340B ID
RRC030092-00
Entity Address
19829 N 27th Ave
Phoenix, AZ 85027
Medicare Provider Number
030092
Participating Start Date
10/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/12/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alice Pope, Chief Financial Officer
(480) 882-5544
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
10/15/2018
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