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OPTUM PHARMACY 702, LLC
CH09312CC FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
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Covered Entity Details
Entity Name
FAMILY HEALTH CENTERS OF SAN DIEGO, INC.
Subdivision Name
KidCare Express Mobile Medical Unit
Type
HRSA-Funded Health Center
340B ID
CH09312CC
Entity Address
823 Gateway Center Way
San Diego, CA 92102-4541
Grant Number
H80CS00224
Participating Start Date
1/1/2011
Last Recertification Date
3/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ricardo Roman, CFO
(619) 906-4603
Contract Pharmacy Representative
Briova
Joseph L Lovino, Manager, 340B Specialty Program
(412) 445-4495
Signed By Date
10/15/2019
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