Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140054 MACNEAL HOSPITAL

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 # 1965
7200 W. CERMAK RD.
NORTH RIVERSIDE, IL 60546

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

340B Drug Pricing Program Database