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CYSTIC FIBROSIS SERVICES, LLC
DSH140029 COPLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COPLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140029
Entity Address
2000 OGDEN AVENUE
AURORA, IL 60504
Medicare Provider Number
140029
Participating Start Date
4/1/2008
Last Recertification Date
8/29/2024
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
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brenda VanWyhe, SENIOR VP FINANCE AND CFO
(630) 898-3565
Contract Pharmacy Representative
Walgreen Co.
Jeremy Mobley, 340B Client Advocate
(847) 964-8974
Signed By Date
1/14/2020
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