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OPTUM PHARMACY 702, LLC
STD705461 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
STD705461
Entity Address
422 Kade Drive
STE 1
Jennings, LA 70546
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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