Contract Pharmacy Details

OPTUM FRONTIER THERAPIES II, LLC
DSH340047 NORTH CAROLINA BAPTIST HOSPITAL

Covered Entity Details

Entity Name

NORTH CAROLINA BAPTIST HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH340047

Entity Address

MEDICAL CENTER BOULEVARD
WINSTON-SALEM, NC 27157

Medicare Provider Number

340047

Participating Start Date

4/1/1998

Last Recertification Date

8/23/2024

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

10/17/2019

Contract Begin Date

1/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/31/2020
Pharmacy closed

Contacts

Covered Entity Signing Official

Conrad Emmerich, Sr. Vice President,Hospital & Business Services
(336) 716-8941

Contract Pharmacy Representative

Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677

Signed By Date

10/17/2019

340B Drug Pricing Program Database