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OSF HOME INFUSION PHARMACY
DSH140110 OTTAWA REGIONAL HOSPITAL & HEALTHCARE CENTER D/B/A OSF SAINT ELIZABETH MEDICAL CENTER
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Covered Entity Details
Entity Name
OTTAWA REGIONAL HOSPITAL & HEALTHCARE CENTER D/B/A OSF SAINT ELIZABETH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140110
Entity Address
1100 EAST NORRIS DRIVE
OTTAWA, IL 61350
Medicare Provider Number
140110
Participating Start Date
7/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
OSF HOME INFUSION PHARMACY
Pharmacy Address
2265 W ALTORFER DR
PEORIA, IL 61615-1807
Pharmacy Comments
Contract Details
Approval Date
7/9/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/10/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
OSF Healthcare
Kelly J Taylor, Manager Pharmacy
(309) 624-5464
Signed By Date
7/9/2021
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