Contract Pharmacy Details

OPTUM PHARMACY 702, LLC
RWI77004 AIDS Healthcare Foundation

Covered Entity Details

Entity Name

AIDS Healthcare Foundation

Subdivision Name

AHF Healthcare Center - Houston Wellness

Type

Ryan White Part A

340B ID

RWI77004

Entity Address

1435 Westheimer Rd.
Houston, TX 77006

Grant Number

H89HA00004

Participating Start Date

1/1/2020

Last Recertification Date

2/15/2023

Entity Termination Date

4/1/2024

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

Contract Termination Date
Termination Reason

4/1/2024
Covered Entity Terminated

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