Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER

Covered Entity Details

Entity Name

LOYOLA UNIVERSITY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140276

Entity Address

2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153

Medicare Provider Number

140276

Participating Start Date

4/1/2010

Last Recertification Date

9/9/2024

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

CVS PHARMACY # 17169
800 BROADVIEW VILLAGE SQ
BROADVIEW, IL 60155

Pharmacy Comments

Contract Details

Approval Date

4/15/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Daniel Paul Isacksen, EVP and Regional CFO
(708) 216-4252

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/15/2020

340B Drug Pricing Program Database