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SOUTH WABASH CVS, L.L.C.
DSH140119 RUSH UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
RUSH UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140119
Entity Address
1653 W CONGRESS PKWY
CHICAGO, IL 60612
Medicare Provider Number
140119
Participating Start Date
12/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
SOUTH WABASH CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 03674
105 S. WABASH AVE.
CHICAGO, IL 60603
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
3/30/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
John Mordach, Chief Financial Officer
(312) 942-5600
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/15/2019
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