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MEDICATE CENTRAL PHARMACY
HV05332D SOUTHERN ILLINOIS HEALTHCARE FOUNDATION (SIHF)
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS HEALTHCARE FOUNDATION (SIHF)
Subdivision Name
SIHF ADULT CARE CENTER
Type
Ryan White Part C
340B ID
HV05332D
Entity Address
6000 BOND AVENUE
CENTREVILLE, IL 62207
Grant Number
H76HA00579
Participating Start Date
7/1/2005
Last Recertification Date
1/26/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
MEDICATE CENTRAL PHARMACY
Pharmacy Address
1833 KINGSHIGHWAY
SUITE 100
WASHINGTON PARK, IL 62204-2135
Pharmacy Comments
Contract Details
Approval Date
7/15/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Larry McCulley, President
(618) 332-0694 Ext: 155
Contract Pharmacy Representative
Signed By Date
7/15/2015
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