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ROUNDY'S SUPERMARKETS INC
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
ROUNDY'S SUPERMARKETS INC
Pharmacy Address
DBA MARIANO'S PHARMACY #8529
4700 GILBERT AVE #14
WESTERN SPRINGS, IL 60558
Pharmacy Comments
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/20/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michele Mazurek, Hospital Chief Administator
(773) 257-5021
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/13/2020
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