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OPTUM FRONTIER THERAPIES II, LLC
SCH260064-00 SSM HEALTH-ST.MARY'S AUDRAIN
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Covered Entity Details
Entity Name
SSM HEALTH-ST.MARY'S AUDRAIN
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260064-00
Entity Address
620 E MONROE
MEXICO, MO 65265
Medicare Provider Number
260064
Participating Start Date
7/1/2018
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
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
7/12/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Donna Jacobs, President, SSM Audrain Health Center
(573) 582-8103
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
7/12/2018
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