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OPTUM FRONTIER THERAPIES II, LLC
DSH520177 FROEDTERT MEMORIAL LUTHERAN HOSPITAL
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Covered Entity Details
Entity Name
FROEDTERT MEMORIAL LUTHERAN HOSPITAL
Subdivision Name
FORMERLY JOHN L. DOYNE HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH520177
Entity Address
9200 WEST WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
520177
Participating Start Date
7/1/1996
Last Recertification Date
8/21/2024
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
4/17/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/4/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925
Contract Pharmacy Representative
David Skomo, Vice President, Specialty Pharmacy Operations
(724) 766-5747
Signed By Date
4/17/2016
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