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OPTUM PHARMACY 702, LLC
FQHC638549 mathiesen memorial Health Clinic
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Covered Entity Details
Entity Name
mathiesen memorial Health Clinic
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638549
Entity Address
18144 Seco Street
Jamestown, CA 95327
Grant Number
Participating Start Date
4/1/2018
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/2/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Richard Vass, CEO
(209) 984-4827 Ext: 2099844827
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/2/2021
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