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HOLIDAY CVS, L.L.C.
DSH140239 Javon Bea Hospital
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Covered Entity Details
Entity Name
Javon Bea Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140239
Entity Address
8201 E Riverside Blvd
Rockford, IL 61114
Medicare Provider Number
140239
Participating Start Date
1/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
HOLIDAY CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04726
24200 VETERANS BLVD
PORT CHARLOTTE, FL 33954
Pharmacy Comments
Contract Details
Approval Date
7/18/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/18/2020
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