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MEDI-PARK PHARMACY
DSH140110 OTTAWA REGIONAL HOSPITAL & HEALTHCARE CENTER D/B/A OSF SAINT ELIZABETH MEDICAL CENTER
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Covered Entity Details
Entity Name
OTTAWA REGIONAL HOSPITAL & HEALTHCARE CENTER D/B/A OSF SAINT ELIZABETH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140110
Entity Address
1100 EAST NORRIS DRIVE
OTTAWA, IL 61350
Medicare Provider Number
140110
Participating Start Date
7/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
MEDI-PARK PHARMACY
Pharmacy Address
420 NE GLEN OAK AVE STE 102
HILLCREST PLAZA
PEORIA, IL 61603-3171
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/10/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
OSF
Tom Terrell, Pharmacy Manager
(309) 655-3799
Signed By Date
4/14/2020
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