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VITAL RX, LLC
DSH140133 HOLY CROSS HOSPITAL
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Covered Entity Details
Entity Name
HOLY CROSS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140133
Entity Address
2701 WEST 68TH STREET
CHICAGO, IL 60629
Medicare Provider Number
140133
Participating Start Date
7/1/2005
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
VITAL RX, LLC
Pharmacy Address
3110 W BELMONT AVE STE 1W
CHICAGO, IL 60618
Pharmacy Comments
Contract Details
Approval Date
10/13/2020
Contract Begin Date
12/7/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donnica Lynn Austin, Vice President of Operations, Acute Care Hospitals
(773) 257-5048
Contract Pharmacy Representative
Vital Rx, LLC
Rick Schumacher, Owner
(773) 862-1699
Signed By Date
10/13/2020
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