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GOTTLIEB COMMUNITY HEALTH SERVICES CORPO
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
GOTTLIEB COMMUNITY HEALTH SERVICES CORPO
Pharmacy Address
DBA MACNEAL OUTPATIENT PHARMACY
3249 OAK PARK AVE STE T1201
BERWYN, IL 60402
Pharmacy Comments
Contract Details
Approval Date
10/21/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723
Contract Pharmacy Representative
Loyola Health
Joseph Hegazin, Regional Manager of Outpatient Pharmacy Services
(708) 717-5320
Signed By Date
10/21/2022
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