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OPTUM PHARMACY 702, LLC
STD34202 CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
Lakewood Ranch
Type
Sexually Transmitted Diseases
340B ID
STD34202
Entity Address
6310 Health Park Way
Suite 345
Lakewood Ranch, FL 34202
Grant Number
1 NH25PS005131-01-00
Participating Start Date
10/1/2019
Last Recertification Date
5/29/2020
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/22/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Richard E. Carlisle, President & CEO
(941) 366-0134 Ext: 11111
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/22/2020
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