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OPTUM PHARMACY 702, LLC
FQHC638544 Menominee Indian Tribe of Wisconsin
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Covered Entity Details
Entity Name
Menominee Indian Tribe of Wisconsin
Subdivision Name
Menominee Tribal Clinic
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638544
Entity Address
W3275 WOLF RIVER ROAD
Keshena, WI 54135
Grant Number
Participating Start Date
1/1/2017
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
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jerry Waukau, Tribal Health Administrator
(715) 799-5482
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
1/17/2023
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