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GOTTLIEB PROFESSIONAL BUILDING PHARMACY
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
GOTTLIEB PROFESSIONAL BUILDING PHARMACY
Pharmacy Address
675 W NORTH AVE
MELROSE PARK, IL 60160-1630
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Post, Executive Vice President
(708) 216-1670
Contract Pharmacy Representative
Gottlieb
Clark Chrisman, Pharmacy Manager
(708) 538-4951
Signed By Date
10/14/2019
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