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OPTUM PHARMACY 702, LLC
STD891042 John Phoenix APRN, PLLC
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Covered Entity Details
Entity Name
John Phoenix APRN, PLLC
Subdivision Name
Huntridge Family Clinic
Type
Sexually Transmitted Diseases
340B ID
STD891042
Entity Address
1820 E Sahara Ave
sUITE 201
Las Vegas, NV 89104
Grant Number
5 NH25PS005179-02-00
Participating Start Date
4/1/2020
Last Recertification Date
5/5/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
3/5/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Phoenix, Chief Clinical Officer
(702) 979-1111
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/6/2020
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