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OPTUM PHARMACY 702, LLC
CH051028A LAKE SUPERIOR COMMUNITY HEALTH CENTER
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Covered Entity Details
Entity Name
LAKE SUPERIOR COMMUNITY HEALTH CENTER
Subdivision Name
LSCHC SUPERIOR CLINIC
Type
HRSA-Funded Health Center
340B ID
CH051028A
Entity Address
2222 E 5th St Bldg
Superior, WI 54880
Grant Number
H80CS00811
Participating Start Date
4/1/2004
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/14/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lee Homan, CEO
(218) 336-3503
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/14/2024
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