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OPTUM FRONTIER THERAPIES II, LLC
DSH520087 Gundersen Lutheran Medical Center, Inc.
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Covered Entity Details
Entity Name
Gundersen Lutheran Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520087
Entity Address
1900 South Ave
La Crosse, WI 54601
Medicare Provider Number
520087
Participating Start Date
7/1/2012
Last Recertification Date
9/6/2024
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
9/2/2020
Contract Begin Date
9/2/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kay P Marsyla, Director, Reimbursement
(608) 775-0171
Contract Pharmacy Representative
Avella/BriovaRx
Paul Leschinert, National Account Manager,340B Sales
(847) 409-0200
Signed By Date
9/2/2020
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