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HIGHLAND PARK CVS, L.L.C.
DSH140239 Javon Bea Hospital
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Covered Entity Details
Entity Name
Javon Bea Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140239
Entity Address
8201 E Riverside Blvd
Rockford, IL 61114
Medicare Provider Number
140239
Participating Start Date
1/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08548
2454 S. ALPINE RD.
ROCKFORD, IL 61108
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
7/14/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126
Contract Pharmacy Representative
CVS
Gabrielle Lagana, Implementation Consultant
(212) 419-4049
Signed By Date
10/14/2019
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