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OPTUM FRONTIER THERAPIES II, LLC
PED503301-00 Mary Bridge Children's Hospital and Health Center
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Covered Entity Details
Entity Name
Mary Bridge Children's Hospital and Health Center
Subdivision Name
Type
Children's Hospital
340B ID
PED503301-00
Entity Address
317 Martin Luther King Jr Way
Tacoma, WA 98405-4234
Medicare Provider Number
503301
Participating Start Date
10/1/2011
Last Recertification Date
8/14/2024
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
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Florence Chang, President
(253) 403-7355
Contract Pharmacy Representative
Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677
Signed By Date
4/12/2019
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