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MEDI-PARK PHARMACY
RRC140064-00 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140064-00
Entity Address
3333 N SEMINARY
GALESBURG, IL 61401
Medicare Provider Number
140064
Participating Start Date
7/1/2018
Last Recertification Date
8/26/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
MEDI-PARK PHARMACY
Pharmacy Address
420 NE GLEN OAK AVE STE 102
HILLCREST PLAZA
PEORIA, IL 61603-3171
Pharmacy Comments
Contract Details
Approval Date
10/5/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
OSF
Tom Terrell, Pharmacy Manager
(309) 655-3799
Signed By Date
10/5/2018
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