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CYSTIC FIBROSIS SERVICES, LLC
RRC140250-00 SOUTH SUBURBAN HOSPITAL
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Covered Entity Details
Entity Name
SOUTH SUBURBAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140250-00
Entity Address
178TH STREET AND KEDZIE AVE
HAZELCREST, IL 60429
Medicare Provider Number
140250
Participating Start Date
10/1/2020
Last Recertification Date
Entity Termination Date
12/21/2020
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/21/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nan Nelson, SVP-Finance
(414) 378-4765
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/14/2020
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