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MAAR ILLINOIS INC.
DSH140083 LORETTO HOSPITAL
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Covered Entity Details
Entity Name
LORETTO HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140083
Entity Address
645 SOUTH CENTRAL
CHICAGO, IL 60644
Medicare Provider Number
140083
Participating Start Date
12/6/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
MAAR ILLINOIS INC.
Pharmacy Address
DBA: AUSTIN OUTPATIENT PHARMACY
645 S. CENTRAL AVE.
CHICAGO, IL 60644-5059
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kenneth McGhee, CFO
(773) 854-5008
Contract Pharmacy Representative
Austin Outpatient Pharmacy
Ronak Manek, Pharmacy Manager
(773) 854-2500
Signed By Date
4/15/2019
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