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MERCY MALL PHARMACY
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
MERCY MALL PHARMACY
Pharmacy Address
1010 N WASHINGTON ST
JANESVILLE, WI 53548-1500
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126
Contract Pharmacy Representative
Mercy Health System
Amy Reilly, MALL PHARMACY MANGER
(608) 755-8747
Signed By Date
1/9/2020
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