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OPTUM PHARMACY 702, LLC
FQHCLA402 Good Samaritan Family Health Center Inc.
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Covered Entity Details
Entity Name
Good Samaritan Family Health Center Inc.
Subdivision Name
Family Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA402
Entity Address
1027 Washington Avenue
Suite B
Vincennes, IN 47591
Grant Number
LALCS33817
Participating Start Date
1/1/2020
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
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer Emmons, CEO
(812) 494-7800
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/13/2023
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