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HIGHLAND PARK CVS, L.L.C.
DSH140054 MACNEAL HOSPITAL
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Covered Entity Details
Entity Name
MACNEAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140054
Entity Address
3249 SOUTH OAK PARK AVENUE
BERWYN, IL 60402
Medicare Provider Number
140054
Participating Start Date
1/1/2019
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08741
2634 S PULASKI
CHICAGO, IL 60623
Pharmacy Comments
Contract Details
Approval Date
4/17/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/14/2024
Pharmacy closed
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
4/17/2020
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