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OPTUM PHARMACY 702, LLC
STD89119 Horizon Ridge Wellness Clinic, Inc
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Covered Entity Details
Entity Name
Horizon Ridge Wellness Clinic, Inc
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD89119
Entity Address
1670 E Flamingo Road, Suite A
Suite A
Las Vegas, NV 89119
Grant Number
5NH25PS005179-04-00
Participating Start Date
6/3/2022
Last Recertification Date
6/4/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
6/3/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bruce Eddins, Chief Administrator
(702) 489-2889 Ext: 102
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
5/19/2022
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