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OPTUM PHARMACY 702, LLC
RWI19147 Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Type
Ryan White Part A
340B ID
RWI19147
Entity Address
1348 Bainbridge Street
Philadelphia, PA 19147-1810
Grant Number
H89HA00013
Participating Start Date
4/1/2018
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
OPTUM PHARMACY 702, LLC
Pharmacy Address
1050 PATROL RD
JEFFERSONVILLE, IN 47130
Pharmacy Comments
Contract Details
Approval Date
4/6/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ronald Powers, COO
(215) 563-0652 Ext: 210
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
4/6/2018
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