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OPTUM FRONTIER THERAPIES II, LLC
DSH410007 RHODE ISLAND HOSPITAL
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Covered Entity Details
Entity Name
RHODE ISLAND HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410007
Entity Address
593 EDDY STREET
PROVIDENCE, RI 02903
Medicare Provider Number
410007
Participating Start Date
4/1/2004
Last Recertification Date
8/19/2024
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
4/7/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Mary Wakefield, Senior VP and CFO
(401) 444-7093
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/7/2020
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