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CORAM ALTERNATE SITE SERVICES, INC.
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
CORAM ALTERNATE SITE SERVICES, INC.
Pharmacy Address
DBA CORAM CVS/SPECIALTY INFUSION SERVICE
1471 E BUSINESS CENTER DRIVE
SUITE 500
MOUNT PROSPECT, IL 60056
Pharmacy Comments
Contract Details
Approval Date
7/20/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/7/2025
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
7/20/2020
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