Covered Entity Details

CH05758R UNIVERSITY OF ILLINOIS (Active) - information as of 4/24/2025 11:59:25 PM

Main Details

Name

UNIVERSITY OF ILLINOIS

Subdivision Name

University of Illinois Medical Center - Mile Square Health Center at South Shore

Type

HRSA-Funded Health Center

Site ID

BPS-H80-019383

340B ID

CH05758R

Grant Number

H80CS00324

Additional Details

Current Program Status

Active

Registration Date

1/31/2018

Participating Start Date

2/1/2018

Participating Approval Date

2/1/2018

Last Recertification Date

2/23/2025

Contacts

Authorizing Official

University of Illinois at Chicago
Michael Moss, Associate Vice Chancellor, Budget & Financial Analysis
(312) 996-0306

Primary Contact

UI Health Mile Square Health Center
Phyllis Grice, Chief Operating Officer
(312) 413-0728

Addresses

Street Address

7037 S. Stony Island Avenue
Chicago, IL 60649-1905

Billing Address

University of Illinois
Invoice Processing Center
PO Box 820
Rantoul, IL 61866

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
IL	376000511-043	1760400170

Shipping Addresses

Shipping Address 1

University of Illinois Mile Square Pharmacy
1220 S Wood Street
Room 1045
Chicago, IL 60608

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
Contract Detail	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	02/01/2018	02/01/2018			02/01/2018

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH057580	Active	BPS-H80-013573	University of Illinois	University of Illinois Mile Square Health Center - IMD	1220 S. Wood Street	Chicago	IL
CH05758A	Active	BPS-H80-011981	University of Illinois	Mile Square Health Center at Englewood	641 West 63rd Street, 1ST FL Suite A	Chicago	IL
CH05758B	Terminated	BPS-H80-010036	University of Illinois	Mile Square Health Center- Hope Health and Wellness Center	1628 W. Washington Blvd	Chicago	IL
CH05758C	Active	BPS-H80-005757	University of Illinois	National Teachers Academy	55 West Cermak Road	Chicago	IL
CH05758D	Terminated	BPS-H80-006064	University of Illinois	Mile Square Health Center, Young Women's Leadership/Drake Health and Wellness Center	2641 South Calumet Avenue	Chicago	IL
CH05758E	Active	BPS-H80-011549	University of Illinois	Mile Square Health Center, Davis Health and Wellness Center	3050 W 39TH PL	CHICAGO	IL
CH05758G	Terminated	BPS-H80-000959	University of Illinois	Mile Square IHC North Center Clinic	4221 N Lincoln Avenue	Chicago	IL
CH05758H	Terminated	BPS-H80-002347	University of Illinois	Mile Square IHC New City Clinic	734 West 47th Street	Chicago	IL
CH05758J	Active	BPS-H80-002949	University of Illinois	Mile Square Health Center at Back of the Yards	4630 South Bishop Street	Chicago	IL
CH05758K	Terminated	BPS-H80-000173	University of Illinois	Mile Square Health Center at South Shore	7131 S Jeffery Blvd	Chicago	IL
CH05758L	Active	BPS-H80-008724	University of Illinois	Mile Square Health Center at Cicero	4747-51 West Cermak Road	Cicero	IL
CH05758M	Terminated	BPS-H80-014154	UNIVERSITY OF ILLINOIS	Mile Square-Auburn Gresham Health and Wellness Center	8131 S MAY ST	CHICAGO	IL
CH05758N	Terminated	BPS-H80-013800	UNIVERSITY OF ILLINOIS	UNIVERSITY OF ILLINOIS MILE SQUARE HEALTH CENTER - HUMBOLDT PARK	3240 W DIVISION ST	CHICAGO	IL
CH05758P	Terminated	BPS-H80-018940	UNIVERSITY OF ILLINOIS	Mile Square Englewood STEM-Cook Satellite	8150 South Bishop	Chicago	IL
CH05758Q	Terminated	BPS-H80-019040	UNIVERSITY OF ILLINOIS	Mile Square Davis-Brighton Park Satellite	3825 South Washtenaw	Chicago	IL
CH05758R	Active	BPS-H80-019383	UNIVERSITY OF ILLINOIS	University of Illinois Medical Center - Mile Square Health Center at South Shore	7037 S. Stony Island Avenue	Chicago	IL
CH05758S	Active	BPS-H80-027383	UNIVERSITY OF ILLINOIS	Mile Square Dr. Cynthia Barnes Boyd/Drake Health and Wellness Center	2710 S. Dearborn	Chicago	IL
CH05758T	Active	BPS-H80-028185	UNIVERSITY OF ILLINOIS	Mile Square Englewood Health and Wellness Center	6835 S Normal Blvd Rm H-102	Chicago	IL
CH05758U	Active	BPS-H80-030120	UNIVERSITY OF ILLINOIS	UI Health Mile Square Health Center L.P. Johnson Rockford	1221 E State St	Rockford	IL
CH05758V	Active	BPS-H80-033882	UNIVERSITY OF ILLINOIS	UI Health Mile Square Health Center Primary and Immediate Care Center	839 W 79th Street FL 2	Chicago	IL
CH05758W	Active	BPS-H80-033773	University of Illinois	UI Health Mile Square Health Center Back of the Yards Dental	4634 S Bishop St	Chicago	IL

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05033	2015 E 79TH ST	CHICAGO	IL	60649	04/01/2017	11/06/2024
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03074	4700 S. HALSTED ST	CHICAGO	IL	60609	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03961	2340 W MADISON ST	CHICAGO	IL	60612	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03395	3401 W ROOSEVELT RD	CHICAGO	IL	60624	04/01/2017	11/12/2024
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05103	5932 W. CERMAK RD	CICERO	IL	60804	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 01417	1931 W CERMAK RD	CHICAGO	IL	60608	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02025	3000 S HALSTED	CHICAGO	IL	60608	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05356	4710 S WESTERN AVE	CHICAGO	IL	60609	04/01/2017
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 11410	1627 N PULASKI RD	CHICAGO	IL	60639	07/01/2020
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04938	4748 W NORTH AVE	CHICAGO	IL	60639	07/01/2020
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02903	5222 WEST MADISON ST	CHICAGO	IL	60644	07/01/2020
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02877	2440 W NORTH AVE	CHICAGO	IL	60647	07/01/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 06003	3336 11TH STREET	ROCKFORD	IL	61109	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04150	230 W. CHRYSLER DR.	BELVIDERE	IL	61008	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03322	2323 CHARLES STREET	ROCKFORD	IL	61104	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04777	2525 S ALPINE ROAD	ROCKFORD	IL	61108	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02585	3803 AUBURN STREET	ROCKFORD	IL	61101	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02828	1602 KISHWAUKEE ST	ROCKFORD	IL	61104	07/28/2020
CH05758U	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03283	3325 N. MAIN STREET	ROCKFORD	IL	61103	07/28/2020
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 06003	3336 11TH STREET	ROCKFORD	IL	61109	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04150	230 W. CHRYSLER DR.	BELVIDERE	IL	61008	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02585	3803 AUBURN STREET	ROCKFORD	IL	61101	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03322	2323 CHARLES STREET	ROCKFORD	IL	61104	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 02828	1602 KISHWAUKEE ST	ROCKFORD	IL	61104	10/01/2021	02/19/2025
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 03283	3325 N. MAIN STREET	ROCKFORD	IL	61103	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04777	2525 S ALPINE ROAD	ROCKFORD	IL	61108	10/01/2021
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04978	111 S. HALSTED STREET	CHICAGO	IL	60661	04/01/2023
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 04306	1633 W. 95TH STREET	CHICAGO	IL	60643	04/01/2023
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05234	5435 S KEDZIE AVE	CHICAGO	IL	60632	04/01/2023
CH057580	BOND DRUG COMPANY OF ILLINOIS, L.L.C.	DBA: WALGREENS # 05034	6315 S KEDZIE AVE	CHICAGO	IL	60629	04/01/2023
CH057580	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	08/21/2007
CH05758L	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013
CH05758A	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013
CH05758B	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013	04/01/2024
CH05758C	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013
CH05758D	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013	01/01/2020
CH05758E	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013
CH05758G	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013	10/01/2016
CH05758H	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013	04/01/2017
CH05758J	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013
CH05758K	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2013	04/01/2018
CH05758N	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2015	01/01/2024
CH05758M	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2015	01/01/2020
CH05758P	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	04/01/2018	04/01/2024
CH05758R	UNIVERSITY OF ILLINOIS MILE SQUARE PHARM	1220 S WOOD ST STE 1045		CHICAGO	IL	60608	02/01/2018
CH05758U	WALGREEN CO	DBA: WALGREENS #10938	1080 N. 7TH ST	ROCHELLE	IL	61068	07/28/2020
CH05758U	WALGREEN CO	DBA; WALGREENS #12583	1704 E. RIVERSIDE BLVD	LOVES PARK	IL	61111	07/28/2020
CH057580	WALGREEN CO	DBA: WALGREENS #10938	1080 N. 7TH ST	ROCHELLE	IL	61068	10/01/2021
CH057580	WALGREEN CO	DBA; WALGREENS #12583	1704 E. RIVERSIDE BLVD	LOVES PARK	IL	61111	10/01/2021
CH057580	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	04/01/2023
CH057580	WALGREEN CO.	DBA: WALGREENS # 10350	7109 S JEFFERY BLVD	CHICAGO	IL	60649-2425	04/01/2017	02/27/2025
CH057580	WALGREEN CO.	DBA: WALGREENS # 06641	1614 W 47TH STREET	CHICAGO	IL	60609-3245	04/01/2017
CH057580	WALGREEN CO.	DBA: WALGREENS # 01101	1533 E 67TH ST	CHICAGO	IL	60637-4426	04/01/2017
CH057580	WALGREEN CO.	DBA: WALGREENS # 03539	11 E 75TH STREET	CHICAGO	IL	60619	04/01/2017
CH057580	WALGREEN CO.	DBA: WALGREENS # 05124	8628 S COTTAGE GROVE AVE	CHICAGO	IL	60619	04/01/2017
CH057580	WALGREEN CO.	DBA: WALGREENS # 01249	4800 W CERMAK RD	CICERO	IL	60804	04/01/2017	11/06/2024
CH057580	WALGREEN CO.	DBA: WALGREENS # 07267	650 W 63RD ST	CHICAGO	IL	60621-2012	04/01/2017
CH057580	WALGREEN CO.	DBA: WALGREENS # 00232	3405 S KING DR	CHICAGO	IL	60616	04/01/2017	02/26/2025
CH057580	WALGREEN CO.	DBA: WALGREENS # 05926	4385 S ARCHER AVE	CHICAGO	IL	60632	04/01/2017
CH057580	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #16498	2351 E 71ST ST SUITE A	CHICAGO	IL	60649	04/01/2017
CH05758U	WALGREEN CO.	WALGREENS PHARMACY AT CRUSADERS #21287	1200 W STATE ST STE 102	ROCKFORD	IL	61102-2112	07/28/2020
CH05758U	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21184	5503 E STATE ST	ROCKFORD	IL	61108	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 01515	5900 N SECOND ST	LOVES PARK	IL	61111	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 06002	1201 E STATE ST	ROCKFORD	IL	61104	07/28/2020	02/19/2024
CH05758U	WALGREEN CO.	DBA: WALGREENS #12555	2404 S PERRYVILLE RD	ROCKFORD	IL	61108	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 09127	1145 N ALPINE RD	ROCKFORD	IL	61107-3613	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 06001	5065 HONONEGAH RD	ROSCOE	IL	61073	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 07069	5690 E STATE STREET	ROCKFORD	IL	61108	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS #12126	1680 WEST LANE RD.	MACHESNEY PARK	IL	61115	07/28/2020
CH05758U	WALGREEN CO.	DBA: WALGREENS # 06004	3929 N MULFORD RD	ROCKFORD	IL	61114-5672	07/28/2020
CH057580	WALGREEN CO.	DBA: WALGREENS # 06001	5065 HONONEGAH RD	ROSCOE	IL	61073	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 06002	1201 E STATE ST	ROCKFORD	IL	61104	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 09127	1145 N ALPINE RD	ROCKFORD	IL	61107-3613	10/01/2021
CH057580	WALGREEN CO.	WALGREENS PHARMACY AT CRUSADERS #21287	1200 W STATE ST STE 102	ROCKFORD	IL	61102-2112	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 01515	5900 N SECOND ST	LOVES PARK	IL	61111	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS #12555	2404 S PERRYVILLE RD	ROCKFORD	IL	61108	10/01/2021
CH057580	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21184	5503 E STATE ST	ROCKFORD	IL	61108	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 06004	3929 N MULFORD RD	ROCKFORD	IL	61114-5672	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS #12126	1680 WEST LANE RD.	MACHESNEY PARK	IL	61115	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 07069	5690 E STATE STREET	ROCKFORD	IL	61108	10/01/2021
CH057580	WALGREEN CO.	DBA: WALGREENS # 00162	1554 E 55TH ST	CHICAGO	IL	60615	04/01/2023
CH057580	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #13832	4339 DIPAOLO CENTER	GLENVIEW	IL	60025	04/01/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Recertification	Lee, Kimary Senior Director Compliance and Development UI Health Mile Square Health Center 3124130278	Grice, Phyllis Chief Operating Officer UI Health Mile Square Health Center 3124130728	2/23/2025 1:48 PM
Details	Last Recertification Date	Update	Recertification	2/12/2024 8:57:34 AM	2/23/2025 1:48:00 PM	2/23/2025 1:48 PM
Details	Last Recertification Date	Update	Recertification	2/14/2023 11:11:50 AM	2/12/2024 8:57:34 AM	2/12/2024 8:57 AM
Contacts	Primary Contact	Update	Group Change Request	Inman, Rhondi Assistant Director University of Illinois Mile Square 3124131767	Lee, Kimary Senior Director Compliance and Development UI Health Mile Square Health Center 3124130278	6/15/2023 11:28 AM
Details	Last Recertification Date	Update	Recertification	2/21/2022 9:24:56 AM	2/14/2023 11:11:50 AM	2/14/2023 11:11 AM
Details	Last Recertification Date	Update	Recertification	2/4/2021 9:48:15 AM	2/21/2022 9:24:56 AM	2/21/2022 9:24 AM
Contacts	Authorizing Official	Update	Profile Change Request	Moss, Michael Assistant Chancellor and Director, Budget & Financial Analysis University of Illinois at Chicago 3129960306	Moss, Michael Associate Vice Chancellor, Budget & Financial Analysis University of Illinois at Chicago 3129960306	2/3/2022 9:55 AM
Contacts	Signed By	Update	Profile Change Request	Moss, Michael Assistant Chancellor and Director, Budget & Financial Analysis University of Illinois at Chicago 3129960306	Moss, Michael Associate Vice Chancellor, Budget & Financial Analysis University of Illinois at Chicago 3129960306	2/3/2022 9:55 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1760400170	2/4/2021 9:48 AM
Medicaid Billing	NPI: State	Insert	Recertification		IL	2/4/2021 9:48 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1760400170 ( )		2/4/2021 9:48 AM
Contacts	Primary Contact	Update	Recertification	Shah, Sima 340B Compliance Coordinator/Clinical Assistant Professor Mile Square Health Center 3129963692	Inman, Rhondi Assistant Director University of Illinois Mile Square 3124131767	2/4/2021 9:48 AM
Details	Last Recertification Date	Update	Recertification	1/31/2020 6:01:16 PM	2/4/2021 9:48:15 AM	2/4/2021 9:48 AM
Details	Last Recertification Date	Update	Recertification	2/19/2019 4:05:44 PM	1/31/2020 6:01:16 PM	1/31/2020 6:01 PM
Details	Last Recertification Date	Update	Recertification	2/21/2018 5:14:38 PM	2/19/2019 4:05:44 PM	2/19/2019 4:05 PM
Details	Last Recertification Date	Update	Recertification		2/21/2018 5:14:38 PM	2/21/2018 5:14 PM
Details	State	Update	OPA Edit	Approved	Active	2/1/2018 8:26 AM
Dates	Start Date	Update	OPA Edit	4/1/2018 12:00:00 AM	2/1/2018 12:00:00 AM	2/1/2018 8:26 AM
Contacts	Signed By	Insert	New Registration		Moss, Michael Assistant Chancellor and Director, Budget & Financial Analysis University of Illinois at Chicago 3129960306	2/1/2018 8:21 AM
Details	340B ID	Update	New Registration		CH05758R	2/1/2018 8:21 AM
Dates	Participating Approval Date	Update	New Registration		2/1/2018 8:21:22 AM	2/1/2018 8:21 AM
Details	State	Update	New Registration	Pending	Approved	2/1/2018 8:21 AM
Dates	Signed By Date	Update	New Registration		1/31/2018 5:33:56 PM	2/1/2018 8:21 AM
Dates	Start Date	Update	New Registration		4/1/2018 12:00:00 AM	2/1/2018 8:21 AM
Addresses	Main Address	Insert	New Registration		7037 S. Stony Island Avenue Chicago, IL 60649-1905	1/31/2018 3:25 PM
Addresses	Billing Address	Insert	New Registration		University of Illinois Invoice Processing Center PO Box 820 Rantoul, IL 61866	1/31/2018 3:25 PM
Addresses	Shipping Address	Insert	New Registration		University of Illinois Mile Square Pharmacy 1220 S Wood Street Room 1045 Chicago, IL 60608	1/31/2018 3:25 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	1/31/2018 3:25 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		376000511-043	1/31/2018 3:25 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		IL	1/31/2018 3:25 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1760400170	1/31/2018 3:25 PM
Contacts	Authorizing Official	Insert	New Registration		Moss, Michael Assistant Chancellor and Director, Budget & Financial Analysis University of Illinois at Chicago 3129960306	1/31/2018 3:25 PM
Contacts	Primary Contact	Insert	New Registration		Shah, Sima 340B Compliance Coordinator/Clinical Assistant Professor Mile Square Health Center 3129963692	1/31/2018 3:25 PM
Details	Last Recertification Date	Insert	New Registration			1/31/2018 3:25 PM
Details	Grant Number	Insert	New Registration		H80CS00324	1/31/2018 3:25 PM
Details	340B ID	Insert	New Registration			1/31/2018 3:25 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			1/31/2018 3:25 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			1/31/2018 3:25 PM
Details	Medicare Provider Number	Insert	New Registration			1/31/2018 3:25 PM
Details	Entity Name	Insert	New Registration		UNIVERSITY OF ILLINOIS	1/31/2018 3:25 PM
Details	Program Code	Insert	New Registration		CH	1/31/2018 3:25 PM
Details	Entity Subname	Insert	New Registration		University of Illinois Medical Center - Mile Square Health Center at South Shore	1/31/2018 3:25 PM
Dates	Participating Approval Date	Insert	New Registration			1/31/2018 3:25 PM
Details	State	Insert	New Registration		Pending	1/31/2018 3:25 PM
Dates	Registration Date	Insert	New Registration		1/31/2018 3:25:55 PM	1/31/2018 3:25 PM
Dates	Signed By Date	Insert	New Registration			1/31/2018 3:25 PM
Dates	Start Date	Insert	New Registration			1/31/2018 3:25 PM
Terminations	Termination Comments	Insert	New Registration			1/31/2018 3:25 PM
Terminations	Termination Date	Insert	New Registration			1/31/2018 3:25 PM
Terminations	Termination Effective Date	Insert	New Registration			1/31/2018 3:25 PM
Terminations	Termination Reason	Insert	New Registration			1/31/2018 3:25 PM

340B Drug Pricing Program Database