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OPTUM FRONTIER THERAPIES II, LLC
DSH260195 CITIZENS MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
CITIZENS MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260195
Entity Address
1500 NORTH OAKLAND
BOLIVAR, MO 65613
Medicare Provider Number
260195
Participating Start Date
4/1/2022
Last Recertification Date
8/18/2024
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
10/17/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gary Dene Fulbright, Chief Financial Officer
(417) 328-6402
Contract Pharmacy Representative
Briova Rx
Joe Iovino, Manager
(412) 445-4495
Signed By Date
10/17/2017
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