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OPTUM PHARMACY 702, LLC
STD700701 Cardiovascular Institute of the South
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Covered Entity Details
Entity Name
Cardiovascular Institute of the South
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD700701
Entity Address
107 Maryland Drive
luling, LA 70070
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
4/11/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ryan Hebert, CEO
(985) 873-5670
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/11/2025
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