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AMERICAN DRUG STORES LLC
DSH140029 COPLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COPLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140029
Entity Address
2000 OGDEN AVENUE
AURORA, IL 60504
Medicare Provider Number
140029
Participating Start Date
4/1/2008
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
AMERICAN DRUG STORES LLC
Pharmacy Address
DBA OSCO DRUG 3219
129 S RANDALL ROAD
BATAVIA, IL 60510
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/27/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brenda VanWyhe, SENIOR VP FINANCE AND CFO
(630) 898-3565
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/15/2020
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