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CYSTIC FIBROSIS SERVICES, LLC
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
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
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
John Cook, Senior VP / CFO
(608) 756-6642
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2019
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