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OPTUM FRONTIER THERAPIES II, LLC
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus
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Covered Entity Details
Entity Name
Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520009
Entity Address
1506 S. Oneida St.
Appleton, WI 54915
Medicare Provider Number
520009
Participating Start Date
4/1/2012
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
7/10/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Monica Ann Hilt, President
(920) 831-8913
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/10/2020
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