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OPTUM PHARMACY 702, LLC
STD85345 Your Health and Wellness PLLC
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Covered Entity Details
Entity Name
Your Health and Wellness PLLC
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD85345
Entity Address
8466 W Peoria Avenue
Suite 9
Peoria, AZ 85345
Grant Number
NU62PS924550
Participating Start Date
7/1/2024
Last Recertification Date
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
5/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Knoblauch, Owner
(602) 625-7944
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2024
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