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OPTUM FRONTIER THERAPIES II, LLC
DSH030023 FLAGSTAFF MEDICAL CENTER
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Covered Entity Details
Entity Name
FLAGSTAFF MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030023
Entity Address
1200 NORTH BEAVER
FLAGSTAFF, AZ 86001
Medicare Provider Number
030023
Participating Start Date
7/1/2009
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
4/16/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/3/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carole Peet, Chief Administrative Officer
(928) 639-6028
Contract Pharmacy Representative
Avella
Tammy Sievert, 340B Implementation and Analytics Manager, Corportate
(602) 769-3073
Signed By Date
4/16/2019
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