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KMART STORES OF IL LLC 9339
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
KMART STORES OF IL LLC 9339
Pharmacy Address
4101 W 95TH STREET
OAK LAWN, IL 60453
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/29/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Loren Chandler, EVP COO
(773) 257-5658
Contract Pharmacy Representative
Sears
Jennifer Speares, Director of Administration and Compliance
(847) 286-5116
Signed By Date
4/15/2016
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