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HIGHLAND PARK CVS, L.L.C.
DSH140276EP LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Oak Brook Terrace - CAT Scan Imaging Services - Oak Brook Terrace - CAT Scan Imaging Services
Type
Disproportionate Share Hospital
340B ID
DSH140276EP
Entity Address
1 S 260 Summit Avenue
Oakbrook Terrace, IL 60181
Medicare Provider Number
140276
Outpatient Facility Provider Number
Participating Start Date
10/1/2020
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 00921
1155 W. JEFFERSON ST.
SHOREWOOD, IL 60404
Pharmacy Comments
Contract Details
Approval Date
8/25/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/30/2022
Agreement registered in error
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
7/20/2020
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