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OPTUM PHARMACY 805, INC
CH04392C MANTACHIE RURAL HEALTH CARE INC
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Covered Entity Details
Entity Name
MANTACHIE RURAL HEALTH CARE INC
Subdivision Name
Mantachie Rural Health Care Behavioral Health Clinic
Type
HRSA-Funded Health Center
340B ID
CH04392C
Entity Address
5510 Highway 363
Mantachie, MS 38855
Grant Number
H80CS00096
Participating Start Date
4/1/2018
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 805, INC
Pharmacy Address
1101 N CENTRAL AVE, STE 102
PHOENIX, AZ 85004-1829
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/20/2024
Ownership change
Contacts
Covered Entity Signing Official
MARJORIE MCKINNEY, CEO
(662) 282-4226 Ext: 114
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/15/2020
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