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OPTUM FRONTIER THERAPIES II, LLC
FQHCLA463 Mazzoni Center
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Covered Entity Details
Entity Name
Mazzoni Center
Subdivision Name
Washington West
Type
Health Center Program Look-Alike
340B ID
FQHCLA463
Entity Address
1201 Locust St.
Philadelphia, PA 19107-5409
Grant Number
LALCS52965
Participating Start Date
4/1/2024
Last Recertification Date
2/17/2025
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
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alecia Manley, Executive Operating Officer
(215) 563-0652
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
4/15/2024
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