Contract Pharmacy Details

VICTORY RX INC
DSH140181 SOUTH SHORE HOSPITAL CORPORATION

Covered Entity Details

Entity Name

SOUTH SHORE HOSPITAL CORPORATION

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140181

Entity Address

8012 SOUTH CRANDON AVENUE
CHICAGO, IL 60617-1175

Medicare Provider Number

140181

Participating Start Date

4/1/2022

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

VICTORY RX INC

Pharmacy Address

DBA LOCAL HEALTH PHARMACY
2545 W DIVERSEY AVE STE 104
CHICAGO, IL 60647-7173

Pharmacy Comments

Contract Details

Approval Date

7/5/2022

Contract Begin Date

10/1/2022

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/23/2024
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Timothy A. Caveney, President/CEO
(773) 356-5200

Contract Pharmacy Representative

OneroRx dba Local Health Pharmacy
Michael Wolnerman, RPh, CCIM
(515) 829-0406

Signed By Date

7/5/2022

340B Drug Pricing Program Database