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OPTUM PHARMACY 702, LLC
CH010580 PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE
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Covered Entity Details
Entity Name
PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE
Subdivision Name
PROVIDENCE COMMUNITY HEALTH CENTERS, INC.
Type
HRSA-Funded Health Center
340B ID
CH010580
Entity Address
375 Allens Ave
Providence, RI 02905-5010
Grant Number
H80CS00057
Participating Start Date
7/1/1996
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MERRILL THOMAS, CEO
(401) 444-0400 Ext: 3130
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/12/2022
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