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OPTUM PHARMACY 702, LLC
STD704033 Northlake Gastroenterology Associates, LLP
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Covered Entity Details
Entity Name
Northlake Gastroenterology Associates, LLP
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD704033
Entity Address
16061 Doctors Blvd.
Suite B
Hammond, LA 70403
Grant Number
NH25PS005176
Participating Start Date
10/1/2024
Last Recertification Date
5/9/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Martin Leahy, Manager
(985) 542-1334
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/15/2025
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