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INGALLS PROFESSIONAL PHARM II
DSH140191 INGALLS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
INGALLS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140191
Entity Address
ONE INGALLS DRIVE
HARVEY, IL 60426
Medicare Provider Number
140191
Participating Start Date
9/22/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
INGALLS PROFESSIONAL PHARM II
Pharmacy Address
6701 W 159TH ST
TINLEY PARK, IL 60477
Pharmacy Comments
Contract Details
Approval Date
10/22/2012
Contract Begin Date
10/22/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/2/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KURT E. JOHNSON, CEO
(708) 915-6101
Contract Pharmacy Representative
Dorothy Grzadzinski, President
(708) 915-6364
Signed By Date
10/12/2012
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