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MERCY MALL PHARMACY
DSH520066 MERCY HEALTH SYSTEM CORPORATION
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Covered Entity Details
Entity Name
MERCY HEALTH SYSTEM CORPORATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520066
Entity Address
1000 MINERAL POINT AVE
JANESVILLE, WI 53547-5003
Medicare Provider Number
520066
Participating Start Date
4/1/2019
Last Recertification Date
8/30/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
MERCY MALL PHARMACY
Pharmacy Address
1010 N WASHINGTON ST
JANESVILLE, WI 53548-1500
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Cook, Senior VP / CFO
(608) 756-6642
Contract Pharmacy Representative
Mercy Health System
Amy Reilly, MALL PHARMACY MANGER
(608) 755-8747
Signed By Date
4/9/2019
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