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OPTUM FRONTIER THERAPIES II, LLC
DSH260005AE SSM HEALTH ST. JOSEPH HOSPITAL- SC
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Covered Entity Details
Entity Name
SSM HEALTH ST. JOSEPH HOSPITAL- SC
Subdivision Name
SCCMG Wall Street Pediatrics
Type
Disproportionate Share Hospital
340B ID
DSH260005AE
Entity Address
711 Veterans Memorial Parkway
Suite 200
St. Charles, MO 63303
Medicare Provider Number
260005
Outpatient Facility Provider Number
260005
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
OPTUM FRONTIER THERAPIES II, LLC
Pharmacy Address
6425 SANTA MARGARITA ST UNIT 110
LAS VEGAS, NV 89118-1913
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/11/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Karen D. Rewerts, Regional VP of Financa/CFO
(314) 989-2034
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/10/2018
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