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OPTUM FRONTIER THERAPIES II, LLC
DSH470011 Brattleboro Memorial Hospital
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Covered Entity Details
Entity Name
Brattleboro Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470011
Entity Address
17 Belmont Avenue
Brattleboro, VT 05301
Medicare Provider Number
470011
Participating Start Date
7/1/2014
Last Recertification Date
9/4/2024
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
4/2/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael Rogers, Vice President, Finance
(802) 257-8279
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/2/2020
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