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OPTUM PHARMACY 702, LLC
RWII342371J CAN Community Health, Inc.
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Covered Entity Details
Entity Name
CAN Community Health, Inc.
Subdivision Name
Palmetto
Type
Ryan White Part B
340B ID
RWII342371J
Entity Address
408 7th St W
Palmetto, FL 34221
Grant Number
X07HA00057
Participating Start Date
4/28/2020
Last Recertification Date
2/25/2022
Entity Termination Date
10/1/2022
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
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
10/13/2020
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