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PROVIDENT HOSPITAL OF COOK COUNTY
DSH140124F 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
WOODLAWN CLINIC
Type
Disproportionate Share Hospital
340B ID
DSH140124F
Entity Address
6337 S. Woodlawn Avenue
Chicago, IL 60637
Medicare Provider Number
140124
Outpatient Facility Provider Number
Participating Start Date
10/1/2013
Last Recertification Date
9/2/2020
Entity Termination Date
7/1/2021
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
Contract Termination Date
Termination Reason
7/1/2021
Covered Entity Terminated
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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