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RRC140064-00 ST. MARY MEDICAL CENTER (Terminated)
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Main Details
Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
Rural
Yes
340B ID
RRC140064-00
Medicare Provider Number
140064
Additional Details
Current Program Status
Terminated
Registration Date
4/2/2018
Participating Start Date
7/1/2018
Participating Approval Date
4/27/2018
Last Recertification Date
8/26/2021
Termination Date
Termination Reason
7/1/2022
Change of covered entity type
Contacts
Authorizing Official
OSF Healthcare
Diane L. McGrew, President
(309) 655-2850
Primary Contact
OSF Healthcare
Jerry Storm, Senior Vice President of Pharmacy Services
(309) 655-3489
Addresses
Street Address
3333 N SEMINARY
GALESBURG, IL 61401
Billing Address
OSF Healthcare System
PO Box 6259
Peoria, IL 61601
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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