Contract Pharmacy Details

WALGREEN CO.
RRC140179-00 OSF LITTLE COMPANY OF MARY MEDICAL CENTER

Covered Entity Details

Entity Name

OSF LITTLE COMPANY OF MARY MEDICAL CENTER

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140179-00

Entity Address

2800 WEST 95TH STREET
EVERGREEN PARK, IL 60805

Medicare Provider Number

140179

Participating Start Date

1/1/2019

Last Recertification Date

8/30/2021

Entity Termination Date

10/1/2021

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #13956
155 E. BRUSH HILL ROAD
SUITE D1543
ELMHURST, IL 60126

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

8/31/2020
Pharmacy closed

Contacts

Covered Entity Signing Official

Veronica Cordova, Director of Finance
(708) 229-5103

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

1/15/2019

340B Drug Pricing Program Database