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CYSTIC FIBROSIS SERVICES, LLC
DSH360037 ST. VINCENT CHARITY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. VINCENT CHARITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360037
Entity Address
2351 EAST 22ND STREET
CLEVELAND, OH 44115
Medicare Provider Number
360037
Participating Start Date
1/1/2001
Last Recertification Date
9/12/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JOHN Rusnaczyk, CFO
(216) 363-7718 Ext: 37718
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/16/2019
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