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OPTUM PHARMACY 702, LLC
FQHCLA425 SUNRISE CLINICS
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Covered Entity Details
Entity Name
SUNRISE CLINICS
Subdivision Name
Sunrise Clinics - Santa Rosa
Type
Health Center Program Look-Alike
340B ID
FQHCLA425
Entity Address
117 Camino De Vida Ste 300
Santa Rosa, NM 88435-2267
Grant Number
LALCS40211
Participating Start Date
7/1/2021
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/15/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randal Brown, CEO
(575) 472-4311
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
10/15/2024
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