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OPTUM FRONTIER THERAPIES II, LLC
SCH230097-00 MUNSON MEDICAL CENTER
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Covered Entity Details
Entity Name
MUNSON MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230097-00
Entity Address
1105 SIXTH STREET
TRAVERSE CITY, MI 49684
Medicare Provider Number
230097
Participating Start Date
4/1/2017
Last Recertification Date
8/20/2024
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
1/17/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Hepler, CFO
(231) 935-6702
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
1/17/2020
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