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CAREMARK ILLINOIS SPECIALTY PHARMACY, LL
DSH360025 FIRELANDS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
FIRELANDS REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360025
Entity Address
1111 HAYES AVENUE
SANDUSKY, OH 44870
Medicare Provider Number
360025
Participating Start Date
1/1/2017
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
CAREMARK ILLINOIS SPECIALTY PHARMACY, LL
Pharmacy Address
DBA CVS/SPECIALTY OR CARELONRX SPECIALTY
800 BIERMANN CT STE B
MOUNT PROSPECT, IL 60056
Pharmacy Comments
Contract Details
Approval Date
7/9/2019
Contract Begin Date
7/9/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/12/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel J. Moncher, Executive Vice President & CFO
(419) 557-7793
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/9/2019
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