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OPTUM PHARMACY 706, INC.
FQHCLA463A Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Bainbridge
Type
Health Center Program Look-Alike
340B ID
FQHCLA463A
Entity Address
1348 Bainbridge St
Philadelphia, PA 19147-1810
Grant Number
LALCS52965
Participating Start Date
4/1/2024
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 706, INC.
Pharmacy Address
30-30 47TH AVENUE
SUITE 410
LONG ISLAND CITY, NY 11101
Pharmacy Comments
Contract Details
Approval Date
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alecia Manley, Executive Operating Officer
(215) 563-0652
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/15/2024
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