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EVERGREEN PARK PHARMACY
DSH140179 OSF Little Company of Mary Medical Center
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Covered Entity Details
Entity Name
OSF Little Company of Mary Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140179
Entity Address
2800 WEST 95TH STREET
EVERGREEN PARK, IL 60805
Medicare Provider Number
140179
Participating Start Date
10/1/2021
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
EVERGREEN PARK PHARMACY
Pharmacy Address
2850 W 95TH ST STE 100
EVERGREEN PARK, IL 60805-2703
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
Omar Pharmacy Inc
Hani Abdallah, Manager
(708) 423-4700
Signed By Date
10/13/2021
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