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OPTUM FRONTIER THERAPIES II, LLC
DSH410001 MEMORIAL HOSPITAL OF RHODE ISLAND
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF RHODE ISLAND
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410001
Entity Address
111 BREWSTER ST
PAWTUCKET, RI 02860
Medicare Provider Number
410001
Participating Start Date
7/1/2004
Last Recertification Date
11/15/2017
Entity Termination Date
4/1/2018
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
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James Burke, VP Finance
(401) 737-7010 Ext: 31154
Contract Pharmacy Representative
BriovaRX of Maine
Jeffrey Grosklags, CFO
(952) 205-1000
Signed By Date
10/17/2016
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