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OPTUM PHARMACY 702, LLC
DSH030022 MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
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Covered Entity Details
Entity Name
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030022
Entity Address
MARICOPA COUNTY SPECIAL HEALTH CARE DISTRICT DBA VALLEYWISE HEALTH
2601 EAST ROOSEVELT STREET
PHOENIX, AZ 85008
Medicare Provider Number
030022
Participating Start Date
10/4/2018
Last Recertification Date
8/24/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kris Gaw, Chief Operating Officer
(602) 344-1258
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/16/2017
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