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OPTUM PHARMACY 702, LLC
FQHCLA390 MERCY MEDICAL HEALTH CENTER
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Covered Entity Details
Entity Name
MERCY MEDICAL HEALTH CENTER
Subdivision Name
Mercy Medical Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA390
Entity Address
244 Bond Street
Jonesboro, LA 71251
Grant Number
LALCS31662
Participating Start Date
7/1/2019
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
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kimberly Lynn Brunson, CEO
(318) 259-1100
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
1/15/2025
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