Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RWI761111D AIDS Healthcare Foundation

Covered Entity Details

Entity Name

AIDS Healthcare Foundation

Subdivision Name

AHF Healthcare Center Dallas Market Center

Type

Ryan White Part A

340B ID

RWI761111D

Entity Address

2600 North Stemmons Fwy
Suite 141B
Dallas, TX 75207

Grant Number

H89HA00014

Participating Start Date

1/1/2021

Last Recertification Date

2/20/2025

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 702, LLC

Pharmacy Address

1050 PATROL RD
JEFFERSONVILLE, IN 47130

Pharmacy Comments

Contract Details

Approval Date

1/14/2021

Contract Begin Date

4/1/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Philip Ho, Senior Director of Pharmacy and 340B Compliance
(323) 860-5323

Contract Pharmacy Representative

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

Signed By Date

1/14/2021

340B Drug Pricing Program Database