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OPTUM PHARMACY 702, LLC
HM78723 Ascension Seton
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Covered Entity Details
Entity Name
Ascension Seton
Subdivision Name
Central Texas Center for Bleeding and Clotting Disorders, Children's Blood and Cancer Center of Central Texas
Type
Comprehensive Hemophilia Treatment Center
340B ID
HM78723
Entity Address
4910 Mueller Blvd
200
Austin, TX 78723
Grant Number
H30MC24051-12-00
Participating Start Date
4/1/2024
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/2/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Debra Marie Brown, VP, Patient Care Services and COO
(512) 324-0186
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/2/2024
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