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PRIME THERAPEUTICS SPECIALTY PHARMACY LL
RRC140281-00 NORTHWESTERN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
NORTHWESTERN MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140281-00
Entity Address
251 E HURON
CHICAGO, IL 60611
Medicare Provider Number
140281
Participating Start Date
8/7/2020
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
PRIME THERAPEUTICS SPECIALTY PHARMACY LL
Pharmacy Address
ALLIANCERX WALGREENS PRIME #16568
2354 COMMERCE PARK DRIVE
SUITE 100
ORLANDO, FL 32819-9992
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
10/13/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Francis Donald Fraher, CFO
(312) 926-5236
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/12/2020
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