Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
HV01710A AIDS Arms, Inc.d/b/a Prism Health North Texas

Covered Entity Details

Entity Name

AIDS Arms, Inc.d/b/a Prism Health North Texas

Subdivision Name

South Dallas Clinic

Type

Ryan White Part C

340B ID

HV01710A

Entity Address

4922 Spring Ave
Dallas, TX 75210-1359

Grant Number

H76HA01710

Participating Start Date

7/1/2016

Last Recertification Date

3/3/2025

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

10/12/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

John T. Carlo, CEO
(214) 521-5191

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

10/12/2020

340B Drug Pricing Program Database