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OPTUM FRONTIER THERAPIES II, LLC
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
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
4/15/2020
Contract Begin Date
5/22/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2020
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