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RANDOLPH RX PHARMACY
DSH140133 HOLY CROSS HOSPITAL
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Covered Entity Details
Entity Name
HOLY CROSS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140133
Entity Address
2701 WEST 68TH STREET
CHICAGO, IL 60629
Medicare Provider Number
140133
Participating Start Date
7/1/2005
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
RANDOLPH RX PHARMACY
Pharmacy Address
2751 W 51ST ST
CHICAGO, IL 60632
Pharmacy Comments
Contract Details
Approval Date
4/3/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Loren Chandler, EVP COO
(773) 257-5658
Contract Pharmacy Representative
Helen Randoplh, owner
(773) 434-7186
Signed By Date
4/3/2014
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