Contract Pharmacy Details

OPTUM PHARMACY 806, INC.
FQHC638549 mathiesen memorial Health Clinic

Covered Entity Details

Entity Name

mathiesen memorial Health Clinic

Subdivision Name

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638549

Entity Address

18144 Seco Street
Jamestown, CA 95327

Grant Number

Participating Start Date

4/1/2018

Last Recertification Date

2/28/2025

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 806, INC.

Pharmacy Address

2288 AUBURN BLVD
STE. 102
SACRAMENTO, CA 95821-1618

Pharmacy Comments

Contract Details

Approval Date

7/6/2020

Contract Begin Date

7/6/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/15/2021
Pharmacy closed

Contacts

Covered Entity Signing Official

John Richard Vass, CEO
(209) 984-4827 Ext: 2099844827

Contract Pharmacy Representative

Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677

Signed By Date

7/6/2020

340B Drug Pricing Program Database