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CYSTIC FIBROSIS SERVICES, LLC
DSH140127 ADVOCATE BROMENN MEDICAL CENTER
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Covered Entity Details
Entity Name
ADVOCATE BROMENN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140127
Entity Address
1304 FRANKLIN AVENUE
NORMAL, IL 61761
Medicare Provider Number
140127
Participating Start Date
1/1/2019
Last Recertification Date
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Aron Klein, VP Finance
(309) 268-2410
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2019
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