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CYSTIC FIBROSIS SERVICES, LLC
DSH160104 TRINITY BETTENDORF
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Covered Entity Details
Entity Name
TRINITY BETTENDORF
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160104
Entity Address
4500 UTICA RIDGE ROAD
BETTENDORF, IA 52722
Medicare Provider Number
160104
Participating Start Date
4/1/2017
Last Recertification Date
8/14/2024
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
1/11/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Dave Dellitt, Chief Financial Officer
(309) 779-2218
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/11/2021
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