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OPTUM FRONTIER THERAPIES II, LLC
RRC140223-00 ADVOCATE LUTHERAN GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ADVOCATE LUTHERAN GENERAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140223-00
Entity Address
1775 W. DEMPSTER STREET
PARK RIDGE, IL 60068
Medicare Provider Number
140223
Participating Start Date
4/1/2019
Last Recertification Date
8/14/2024
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
4/10/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nanine Nelson, SVP-Finance
(414) 299-1610
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/10/2020
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