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OPTUM PHARMACY 702, LLC
FQHCLA435A LIFE COAST COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
LIFE COAST COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Life Coast Community Health Center Thibodaux
Type
Health Center Program Look-Alike
340B ID
FQHCLA435A
Entity Address
1101 Audubon Ave Ste S1
Thibodaux, LA 70301-4957
Grant Number
LALCS47057
Participating Start Date
10/1/2022
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
4/14/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shannon Boudreaux, CEO
(985) 492-6170
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/14/2025
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