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OPTUM PHARMACY 702, LLC
RWII78208 San Antonio AIDS Foundation
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Covered Entity Details
Entity Name
San Antonio AIDS Foundation
Subdivision Name
Type
Ryan White Part B
340B ID
RWII78208
Entity Address
818 East Grayson Street
San Antonio, TX 78208-1013
Grant Number
X07HA00054
Participating Start Date
7/1/2016
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
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
10/14/2021
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