Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
CAH141319-00 Henry District Hospital

Covered Entity Details

Entity Name

Henry District Hospital

Subdivision Name

Hammond Henry Hospital

Type

Critical Access Hospital

340B ID

CAH141319-00

Entity Address

600 North College Ave
Geneseo, IL 61254-1099

Medicare Provider Number

141319

Participating Start Date

10/1/2012

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08634
910 W. 4TH ST.
MILAN, IL 61264

Pharmacy Comments

Contract Details

Approval Date

7/9/2021

Contract Begin Date

7/20/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Laura J Domino, Vice President of Patient Care Services
(309) 944-9101

Contract Pharmacy Representative

Hammond-Henry Hospital
Laura J Domino, Vice President of Patient Care Services
(309) 944-9101

Signed By Date

7/9/2021

340B Drug Pricing Program Database