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OPTUM PHARMACY 702, LLC
CHC11427-00 Matagorda Episcopal Health Outreach Program
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Covered Entity Details
Entity Name
Matagorda Episcopal Health Outreach Program
Subdivision Name
MEHOP Administration and Outreach
Type
HRSA-Funded Health Center
340B ID
CHC11427-00
Entity Address
101 Ave F N
Bay City, TX 77414-3144
Grant Number
H80CS12889
Participating Start Date
1/1/2010
Last Recertification Date
2/14/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/4/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tayyab Pasha, DO
(979) 245-2008 Ext: 1121
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/4/2024
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