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OSF HOME INFUSION PHARMACY
RRC140064-00 ST. MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140064-00
Entity Address
3333 N SEMINARY
GALESBURG, IL 61401
Medicare Provider Number
140064
Participating Start Date
7/1/2018
Last Recertification Date
8/26/2021
Entity Termination Date
7/1/2022
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
7/1/2022
Covered Entity Terminated
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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