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MEDI-PARK PHARMACY
DSH140113 OSF Heart of Mary Medical Center
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Covered Entity Details
Entity Name
OSF Heart of Mary Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140113
Entity Address
1400 WEST PARK STREET
URBANA, IL 61801
Medicare Provider Number
140113
Participating Start Date
10/1/2015
Last Recertification Date
9/3/2024
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
1/10/2023
Business decision by covered entity and/or pharmacy
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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