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OPTUM PHARMACY 701, LLC
RWI761111 AIDS HEALTHCARE FOUNDATION
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Covered Entity Details
Entity Name
AIDS HEALTHCARE FOUNDATION
Subdivision Name
AIDS HEALTHCARE CENTER - FORT WORTH
Type
Ryan White Part A
340B ID
RWI761111
Entity Address
400 N. BEACH STREET SUITE 104
FORT WORTH, TX 76111
Grant Number
H89HA00047
Participating Start Date
7/1/2014
Last Recertification Date
2/20/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
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
7/11/2024
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