Contract Pharmacy Details

OPTUM PHARMACY 701, LLC
RWII761111 AIDS HEALTHCARE FOUNDATION

Covered Entity Details

Entity Name

AIDS HEALTHCARE FOUNDATION

Subdivision Name

AHF HEALTHCARE CENTER FORT WORTH

Type

Ryan White Part B

340B ID

RWII761111

Entity Address

400 N. BEACH STREET SUITE 104
FORT WORTH, TX 76111

Grant Number

X07HA00054

Participating Start Date

1/1/2016

Last Recertification Date

2/26/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

OPTUM PHARMACY 701, LLC

Pharmacy Address

1830 S HORNE
MESA, AZ 85204

Pharmacy Comments

Contract Details

Approval Date

7/5/2024

Contract Begin Date

10/1/2024

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Rena DeStefano, Director of Pharmacy Finance
(631) 370-2022

Contract Pharmacy Representative

Optum
Avani Patel, VP, 340B Operations
(763) 330-5555

Signed By Date

7/5/2024

340B Drug Pricing Program Database