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AFFILIATED HEALTH SERVICES, INC.
DSH140290 ST. ALEXIUS MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. ALEXIUS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140290
Entity Address
1555 BARRINGTON ROAD
HOFFMAN ESTATES, IL 60169
Medicare Provider Number
140290
Participating Start Date
7/1/2017
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
AFFILIATED HEALTH SERVICES, INC.
Pharmacy Address
DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/3/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sun C Lee-Such, VP Pharmacy
(224) 273-2390
Contract Pharmacy Representative
Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770
Signed By Date
10/14/2019
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