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OPTUM FRONTIER THERAPIES II, LLC
RRC300003-00 MARY HITCHCOCK MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MARY HITCHCOCK MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC300003-00
Entity Address
ONE MEDICAL CENTER DRIVE
LEBANON, NH 03756-0001
Medicare Provider Number
300003
Participating Start Date
9/28/2010
Last Recertification Date
9/15/2021
Entity Termination Date
7/1/2022
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
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/5/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Thomas J. Siepka, CHIEF PHARMACY OFFICER
(603) 650-5738
Contract Pharmacy Representative
Optum
NATHAN WHITE, Vice President Sales - TPA & Hospital
(813) 949-1951
Signed By Date
4/14/2017
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