Contract Pharmacy Details

AFFILIATED HEALTH SERVICES, INC.
DSH140217 PRESENCE SAINT JOSEPH HOSPITAL ELGIN

Covered Entity Details

Entity Name

PRESENCE SAINT JOSEPH HOSPITAL ELGIN

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140217

Entity Address

77 NORTH AIRLITE ST.
ELGIN, IL 60123

Medicare Provider Number

140217

Participating Start Date

4/1/2021

Last Recertification Date

8/16/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

AFFILIATED HEALTH SERVICES, INC.

Pharmacy Address

DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334

Pharmacy Comments

Contract Details

Approval Date

4/5/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/21/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Kevin Larkin, Chief Financial Officer
(630) 801-2729

Contract Pharmacy Representative

Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770

Signed By Date

4/5/2021

340B Drug Pricing Program Database