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DSH140276S LOYOLA UNIVERSITY MEDICAL CENTER (Terminated)
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Main Details
Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
LOYOLA PRIMARY CARE CENTER AT WHEATON
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH140276S
Medicare Provider Number
140276
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
3/9/2010
Participating Start Date
4/1/2010
Participating Approval Date
3/15/2010
Last Recertification Date
8/25/2016
Termination Date
Termination Reason
7/1/2017
Site closure
Contacts
Authorizing Official
Loyola University Medical Center
Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252
Primary Contact
Loyola University Medical Center
William Pong, Administrative Director, Pharmacy Services
(708) 216-0399
Addresses
Street Address
Loyola University Wheaton Pharmacy
140 EAST LOOP ROAD
WHEATON, IL 60189-8407
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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3/3/2010- DOC. RECD. TO CONFIRM DSH ADJ. %.
03/09/2010
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