Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140239 Javon Bea Hospital

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 # 08655
1004 SHOOTING PARK
PERU, IL 61354

Pharmacy Comments

Contract Details

Approval Date

1/9/2020

Contract Begin Date

4/1/2020

Carve-In Effective Date

Contract Comments

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

1/9/2020

340B Drug Pricing Program Database