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CYSTIC FIBROSIS SERVICES, LLC
DSH140191 INGALLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INGALLS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140191
Entity Address
ONE INGALLS DRIVE
HARVEY, IL 60426
Medicare Provider Number
140191
Participating Start Date
9/22/2005
Last Recertification Date
8/29/2024
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
7/7/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/8/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Douglas S Saegesser, CFO
(708) 915-6110
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/7/2021
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