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OPTUM FRONTIER THERAPIES II, LLC
DSH110044 PHOEBE SUMTER MEDICAL CENTER
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Covered Entity Details
Entity Name
PHOEBE SUMTER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110044
Entity Address
126 Hwy 280 West
AMERICUS, GA 31719
Medicare Provider Number
110044
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
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
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
BRANDI LUNNEBORG, CEO
(229) 931-1280
Contract Pharmacy Representative
Optum Rx/BriovaRx/Avella
Joseph L Iovino, Vice President, 340B Sepcialty Program
(412) 445-4495
Signed By Date
1/15/2020
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