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OPTUM FRONTIER THERAPIES II, LLC
DSH320021 PRESBYTERIAN HOSPITAL
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Covered Entity Details
Entity Name
PRESBYTERIAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320021
Entity Address
1100 CENTRAL AVENUE SE
ALBUQUERQUE, NM 87106
Medicare Provider Number
320021
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
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
10/16/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/3/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Sandra C. Podley, VP Operations PDS
(505) 923-5364
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/16/2017
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