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OPTUM PHARMACY 704, INC.
CH067570 CAPITOL CITY FAMILY HEALTH CENTER INC dba CARESOUTH
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Covered Entity Details
Entity Name
CAPITOL CITY FAMILY HEALTH CENTER INC dba CARESOUTH
Subdivision Name
CAPITOL CITY FAMILY HEALTH CENTER, INC dba CARESOUTH
Type
HRSA-Funded Health Center
340B ID
CH067570
Entity Address
3140 FLORIDA BLVD
BATON ROUGE, LA 70806
Grant Number
H80CS00504
Participating Start Date
10/1/2004
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 704, INC.
Pharmacy Address
5627 UNIVERSITY HTS STE 108
SAN ANTONIO, TX 78249
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Valliere, Chief Executive Officer
(225) 650-2026
Contract Pharmacy Representative
Equiscript, LLC
Anne Lipcsey, Account Executive
(704) 287-8429
Signed By Date
7/15/2024
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