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OPTUM PHARMACY 702, LLC
STD063604 Sagebrush Health Services
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Covered Entity Details
Entity Name
Sagebrush Health Services
Subdivision Name
New England Rheumatology
Type
Sexually Transmitted Diseases
340B ID
STD063604
Entity Address
12 Case St
212
Norwich, CT 06360
Grant Number
6 NU62PS924521-04-02
Participating Start Date
5/9/2023
Last Recertification Date
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/9/2023
Contract Begin Date
6/8/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jami Dybik, Vice President
(843) 814-5177
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/25/2023
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