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OPTUM FRONTIER THERAPIES II, LLC
DSH110034 AU Medical Center, Inc.
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Covered Entity Details
Entity Name
AU Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110034
Entity Address
1120 15TH ST.
AUGUSTA, GA 30912
Medicare Provider Number
110034
Participating Start Date
12/1/1992
Last Recertification Date
8/22/2024
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
7/13/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Lee Ann Liska, Chief Executive Officer
(706) 721-6569
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/13/2018
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