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PROVIDENT HOSPITAL OF COOK COUNTY
DSH140124Q JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY
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Covered Entity Details
Entity Name
JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY
Subdivision Name
Cook County Health at North Riverside (formerly known as CICERO CLINIC)
Type
Disproportionate Share Hospital
340B ID
DSH140124Q
Entity Address
1800 S. Harlem Avenue
Suite A
North Riverside, IL 60546
Medicare Provider Number
140124
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PROVIDENT HOSPITAL OF COOK COUNTY
Pharmacy Address
ATTENTION PHARMACY DEPARTMENT
500 E 51ST ST
ROOM 2050
CHICAGO, IL 60615-2400
Pharmacy Comments
Contract Details
Approval Date
6/20/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
7/1/2019
Contract Comments
Contacts
Covered Entity Signing Official
Ekerete Akpan, Chief Financial Officer
(312) 864-6827
Contract Pharmacy Representative
Cook County Health & Hospitals System
CaTanya Norwood, Senior Director of Pharmacy
(312) 864-2213
Signed By Date
6/20/2019
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