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OPTUM PHARMACY 702, LLC
STD704332 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
STD704332
Entity Address
7015 Hwy 190E. Service Rd
Suite 102
Covington, LA 70433
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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