Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.

Covered Entity Details

Entity Name

GOOD SAMARITAN REGIONAL HEALTH CTR.

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140046-00

Entity Address

1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864

Medicare Provider Number

140046

Participating Start Date

10/1/2015

Last Recertification Date

9/14/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06389
1022 W. MAIN ST.
SALEM, IL 62881

Pharmacy Comments

Contract Details

Approval Date

4/13/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Jeremy Shawn Bradford, President
(618) 899-1002

Contract Pharmacy Representative

cvs
Christian Reid, 340B Program Director
(401) 770-2118

Signed By Date

4/13/2021

340B Drug Pricing Program Database