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OPTUM FRONTIER THERAPIES II, LLC
DSH190002 LAFAYETTE GENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LAFAYETTE GENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190002
Entity Address
1214 COOLIDGE STREET
LAFAYETTE, LA 70503
Medicare Provider Number
190002
Participating Start Date
10/25/2005
Last Recertification Date
9/3/2024
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
10/1/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/6/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
al jude patin, SVP, Chief Operating Officer
(337) 289-7743
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/1/2019
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