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OPTUM PHARMACY 702, LLC
STD850121 Spectrum Medical Care Center
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Covered Entity Details
Entity Name
Spectrum Medical Care Center
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD850121
Entity Address
200 E Monterey Way
Phoenix, AZ 85012
Grant Number
1 NU62PS924550-01-00
Participating Start Date
1/1/2020
Last Recertification Date
5/8/2023
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
11/8/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thanes J Vanig, Chief Medical Officer
(602) 604-9500
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2019
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