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EVERGREEN PARK PHARMACY
RRC140179-00 OSF LITTLE COMPANY OF MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
OSF LITTLE COMPANY OF MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140179-00
Entity Address
2800 WEST 95TH STREET
EVERGREEN PARK, IL 60805
Medicare Provider Number
140179
Participating Start Date
1/1/2019
Last Recertification Date
8/30/2021
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
EVERGREEN PARK PHARMACY
Pharmacy Address
2850 W 95TH ST STE 100
EVERGREEN PARK, IL 60805-2703
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
Omar Pharmacy Inc
Hani Abdallah, Manager
(708) 423-4700
Signed By Date
10/12/2020
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