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OPTUM PHARMACY 701, LLC
CH092890 NORTH COUNTRY HEALTHCARE, INC.
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Covered Entity Details
Entity Name
NORTH COUNTRY HEALTHCARE, INC.
Subdivision Name
NORTH COUNTRY - FLAGSTAFF CLINIC
Type
HRSA-Funded Health Center
340B ID
CH092890
Entity Address
2920 N 4th St
Flagstaff, AZ 86004-1816
Grant Number
H80CS00651
Participating Start Date
7/1/1998
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 701, LLC
Pharmacy Address
1830 S HORNE
MESA, AZ 85204
Pharmacy Comments
Contract Details
Approval Date
7/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/9/2025
Agreement registered in error
Contacts
Covered Entity Signing Official
ANNE NEWLAND, CEO
(928) 522-9564
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/12/2024
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