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OPTUM PHARMACY 705, LLC
PED453304-00 Texas Children's Hospital
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Covered Entity Details
Entity Name
Texas Children's Hospital
Subdivision Name
Type
Children's Hospital
340B ID
PED453304-00
Entity Address
6621 Fannin Street
Houston, TX 77030-2303
Medicare Provider Number
453304
Participating Start Date
1/1/2012
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 705, LLC
Pharmacy Address
1100 LEE BRANCH LN
BIRMINGHAM, AL 35242-7298
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
3/14/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Weldon Gage, Executive Vice President/CFO
(832) 826-8084
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/16/2017
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