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OPTUM PHARMACY 702, LLC
STD704333 Mary Bird Perkins Cancer Center
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Covered Entity Details
Entity Name
Mary Bird Perkins Cancer Center
Subdivision Name
Mary Bird Perkins Cancer Center
Type
Sexually Transmitted Diseases
340B ID
STD704333
Entity Address
1203 S. Tyler St
Covington, LA 70433
Grant Number
NH25PS005176
Participating Start Date
4/1/2025
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
4/7/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jodi Conachen, COO
(225) 215-1210
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/7/2025
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