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OPTUM FRONTIER THERAPIES, LLC
DSH330043 SOUTH SHORE UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SOUTH SHORE UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330043
Entity Address
301 EAST MAIN STREET
BAY SHORE, NY 11706
Medicare Provider Number
330043
Participating Start Date
4/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
OPTUM FRONTIER THERAPIES, LLC
Pharmacy Address
325 W ATHERTON RD
SUITE 1
FLINT, MI 48507-2601
Pharmacy Comments
Contract Details
Approval Date
4/2/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michele L Cusack, Executive Vice President
(516) 321-6058
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
4/2/2024
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