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HIGHLAND PARK CVS, L.L.C.
DSH140164 MEMORIAL HOSPITAL OF CARBONDALE
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF CARBONDALE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140164
Entity Address
405 WEST JACKSON STREET
CARBONDALE, IL 62901
Medicare Provider Number
140164
Participating Start Date
1/1/2009
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06390
2431 W. MAIN ST.
CARBONDALE, IL 62901
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/17/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
REX BUDDE, CEO
(618) 457-5200
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/14/2022
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