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RRC140179-00 OSF LITTLE COMPANY OF MARY MEDICAL CENTER (Terminated)
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Main Details
Name
OSF LITTLE COMPANY OF MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
Rural
No
340B ID
RRC140179-00
Medicare Provider Number
140179
Additional Details
Current Program Status
Terminated
Registration Date
10/12/2018
Participating Start Date
1/1/2019
Participating Approval Date
10/23/2018
Last Recertification Date
8/30/2021
Termination Date
Termination Reason
10/1/2021
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
2800 WEST 95TH STREET
EVERGREEN PARK, IL 60805
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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April 2025
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