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OPTUM PHARMACY 702, LLC
STD33614 CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
North Dale Mabry
Type
Sexually Transmitted Diseases
340B ID
STD33614
Entity Address
6919 North Dale Mabry, Suite 300
Tampa, FL 33614
Grant Number
1 NH25PS005131-01-00
Participating Start Date
1/1/2016
Last Recertification Date
5/17/2023
Entity Termination Date
7/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/22/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Richard E. Carlisle, President & CEO
(941) 366-0134 Ext: 11111
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
10/22/2018
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