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OPTUM PHARMACY 702, LLC
FQHCLA437 Muslim Community & Health Center
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Covered Entity Details
Entity Name
Muslim Community & Health Center
Subdivision Name
Muslim Community & Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA437
Entity Address
803 W Layton Avenue
Milwaukee, WI 53221
Grant Number
LALCS46445
Participating Start Date
1/1/2023
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/13/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ARMAN TAHIR, CEO
(414) 254-1110
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2022
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