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OPTUM FRONTIER THERAPIES II, LLC
DSH260105 SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260105
Entity Address
1201 South Grand Blvd.
ST. LOUIS, MO 63104
Medicare Provider Number
260105
Participating Start Date
4/1/2016
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
4/17/2019
Contract Begin Date
4/17/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/13/2021
Business decision by covered entity and/or pharmacy
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
4/17/2019
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