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OPTUM PHARMACY 801, INC.
CH049100 NORTH MISSISSIPPI PRIMARY HEALTH CARE, INC.
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Covered Entity Details
Entity Name
NORTH MISSISSIPPI PRIMARY HEALTH CARE, INC.
Subdivision Name
Benton Medical Center
Type
HRSA-Funded Health Center
340B ID
CH049100
Entity Address
15921 Boundary Dr
Ashland, MS 38603-7740
Grant Number
H80CS00635
Participating Start Date
9/9/2005
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 801, INC.
Pharmacy Address
24416 N 19TH AVE
STE. 100
PHOENIX, AZ 85085
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
7/14/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JAMES D. NUNNALLY, EXECUTIVE DIRECTOR
(662) 224-8951 Ext: 230
Contract Pharmacy Representative
Avella/Briova/Diplomat/Optum
Dorothy M Janetka, 340B HDP Inventory Specialist
(224) 231-1180
Signed By Date
7/14/2020
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