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OPTUM FRONTIER THERAPIES II, LLC
DSH220086 BETH ISRAEL DEACONESS MEDICAL CENTER
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Covered Entity Details
Entity Name
BETH ISRAEL DEACONESS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220086
Entity Address
330 Brookline Ave
BOSTON, MA 02215
Medicare Provider Number
220086
Participating Start Date
10/1/2009
Last Recertification Date
8/30/2024
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
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/9/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEVEN FISCHER, CFO
(617) 667-1961
Contract Pharmacy Representative
BriovaRX of Maine
Jeffrey Grosklags, CFO
(952) 205-1000
Signed By Date
10/17/2016
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