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OPTUM PHARMACY 702, LLC
STD78208 San Antonio AIDS Foundation
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Covered Entity Details
Entity Name
San Antonio AIDS Foundation
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD78208
Entity Address
818 E. Grayson St
San Antonio, TX 78208
Grant Number
NU62PS924529
Participating Start Date
4/1/2017
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/8/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cherise Rohr-Allegrini, Chief Executive Officer
(210) 225-4715 Ext: 122
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/8/2021
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