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HIGHLAND PARK CVS, L.L.C.
DSH140119 RUSH UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
RUSH UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140119
Entity Address
1653 W CONGRESS PKWY
CHICAGO, IL 60612
Medicare Provider Number
140119
Participating Start Date
12/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 02664
11 E 14TH ST.,
CHICAGO HEIGHTS, IL 60411
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Mordach, Chief Financial Officer
(312) 942-5600
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/9/2020
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