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OPTUM FRONTIER THERAPIES II, LLC
CAH031300-00 WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
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Covered Entity Details
Entity Name
WICKENBURG COMMUNITY HOSPITAL ASSOCIATION INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031300-00
Entity Address
520 ROSE LANE
WICKENBURG, AZ 85390
Medicare Provider Number
031300
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
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
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
JIM TAVARY, C.E.O.
(928) 684-4362
Contract Pharmacy Representative
Optum RX
Joseph Iovino, VP
(412) 445-4495
Signed By Date
4/16/2018
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