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OPTUM FRONTIER THERAPIES II, LLC
DSH330195 LONG ISLAND JEWISH MEDICAL CENTER
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Covered Entity Details
Entity Name
LONG ISLAND JEWISH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330195
Entity Address
270-05 76TH AVENUE
NEW HYDE PARK, NY 11040
Medicare Provider Number
330195
Participating Start Date
7/1/2007
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
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/14/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/15/2020
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