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OPTUM PHARMACY 704, INC.
CH090710 COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.
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Covered Entity Details
Entity Name
COMMUNITY HEALTH CENTERS OF THE CENTRAL COAST, INC.
Subdivision Name
NIPOMO COMMUNITY MEDICAL CENTER
Type
HRSA-Funded Health Center
340B ID
CH090710
Entity Address
150 TEJAS PL
NIPOMO, CA 93444-9123
Grant Number
H80CS00621
Participating Start Date
4/1/1996
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
7/7/2021
Contract Begin Date
8/3/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RONALD E. CASTLE, CEO
(805) 459-1835
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/7/2021
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