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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Lori Pacura, President of Acute Care Hospitals
(773) 257-2914
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2019
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