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ROUNDY'S SUPERMARKETS INC
DSH140133 HOLY CROSS HOSPITAL
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Covered Entity Details
Entity Name
HOLY CROSS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140133
Entity Address
2701 WEST 68TH STREET
CHICAGO, IL 60629
Medicare Provider Number
140133
Participating Start Date
7/1/2005
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
ROUNDY'S SUPERMARKETS INC
Pharmacy Address
DBA MARIANO'S PHARMACY #8520
3145 S ASHLAND AVE
CHICAGO, IL 60608
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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