Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
RRC140034-00 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Covered Entity Details

Entity Name

ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140034-00

Entity Address

400 NORTH PLEASANT AVENUE
CENTRALIA, IL 62801

Medicare Provider Number

140034

Participating Start Date

4/1/2011

Last Recertification Date

9/19/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #18091
1129 W BROADWAY
CENTRALIA, IL 62801

Pharmacy Comments

Contract Details

Approval Date

9/24/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Damon Harbison, President
(618) 436-8000

Contract Pharmacy Representative

cvs
Christian Reid, 340B Program Director
(401) 770-2118

Signed By Date

9/24/2020

340B Drug Pricing Program Database