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CAREMARK KANSAS SPECIALTY PHARMACY
DSH140180 Presence Saints Mary and Elizabeth Medical Center
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Covered Entity Details
Entity Name
Presence Saints Mary and Elizabeth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140180
Entity Address
2233 WEST DIVISION STREET
CHICAGO, IL 60622
Medicare Provider Number
140180
Participating Start Date
7/1/2003
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
CAREMARK KANSAS SPECIALTY PHARMACY
Pharmacy Address
CVS/SPECIALTY OR CARELONRX SPECIALTY PHA
11162 RENNER BLVD
LENEXA, KS 66219
Pharmacy Comments
Contract Details
Approval Date
4/4/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/19/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eric M Zornow, CFO
(312) 770-2105
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/4/2022
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