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PRESENCE HOSPITALS PRV PHARMACY
DSH140174 PRESENCE MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
PRESENCE MERCY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140174
Entity Address
1325 NORTH HIGHLAND AVENUE, ATTN: ADMINISTRATION
AURORA, IL 60506
Medicare Provider Number
140174
Participating Start Date
4/1/2010
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PRESENCE HOSPITALS PRV PHARMACY
Pharmacy Address
DBA ST JOSEPH MEDICAL CENTER PHARMACY
333 N. MADISON ST
JOLIET, IL 60435
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kevin Larkin, Chief Financial Officer
(630) 801-2729
Contract Pharmacy Representative
Amita Health
Kimberly Janicek, Regional Pharmacy Director
(815) 741-7142
Signed By Date
1/15/2021
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