Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140182 ADVOCATE NORTH SIDE HEALTH NETWORK

Covered Entity Details

Entity Name

ADVOCATE NORTH SIDE HEALTH NETWORK

Subdivision Name

DBA ADVOCATE ILLINOIS MASONIC MEDICAL CENTER (AIMMC)

Type

Disproportionate Share Hospital

340B ID

DSH140182

Entity Address

836 West Wellington Ave.
CHICAGO, IL 60657

Medicare Provider Number

140182

Participating Start Date

10/27/2005

Last Recertification Date

8/14/2024

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08695
3101 N. CLARK
CHICAGO, IL 60657

Pharmacy Comments

Contract Details

Approval Date

7/20/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/9/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

JACK GILBERT, VP FINANCE
(773) 296-7809

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/20/2017

340B Drug Pricing Program Database