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OPTUM FRONTIER THERAPIES II, LLC
RRC230029-00 ST. JOSEPH MERCY HOSPITAL-OAKLAND
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Covered Entity Details
Entity Name
ST. JOSEPH MERCY HOSPITAL-OAKLAND
Subdivision Name
Type
Rural Referral Center
340B ID
RRC230029-00
Entity Address
44405 WOODWARD AVENUE
PONTIAC, MI 48341
Medicare Provider Number
230029
Participating Start Date
2/2/2021
Last Recertification Date
8/25/2021
Entity Termination Date
7/1/2022
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
2/3/2021
Contract Begin Date
2/4/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Gusho, Regional Chief Financial Officer
(248) 858-6174
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
2/3/2021
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