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AMERICAN DRUG STORES LLC
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
AMERICAN DRUG STORES LLC
Pharmacy Address
OSCO DRUG 4057
10203 GRAND AVE
FRANKLIN PARK, IL 60131-3140
Pharmacy Comments
Contract Details
Approval Date
4/8/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Post, Executive Vice President
(708) 216-1670
Contract Pharmacy Representative
Safeway
charles Hanson, 340B program manager
(208) 395-6304
Signed By Date
4/8/2019
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