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OPTUM PHARMACY 702, LLC
STD741041 Community Nursing Center of Oklahoma City DBA Diversity Family Health
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Covered Entity Details
Entity Name
Community Nursing Center of Oklahoma City DBA Diversity Family Health
Subdivision Name
Diversity Family Health-Tulsa
Type
Sexually Transmitted Diseases
340B ID
STD741041
Entity Address
1822 E15th Street
Suite A
Tulsa, OK 74104
Grant Number
NH25PS005143
Participating Start Date
1/1/2021
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
1/14/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Russell Ryan Rooms, Director
(405) 848-0026
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/14/2025
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