Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140064 ST. MARY MEDICAL CENTER

Covered Entity Details

Entity Name

ST. MARY MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140064

Entity Address

3333 N SEMINARY Street
GALESBURG, IL 61401

Medicare Provider Number

140064

Participating Start Date

7/1/2023

Last Recertification Date

9/3/2024

Entity Termination Date

4/1/2025

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

CVS PHARMACY # 16324
1071 W CARL SANDBURG DR
GALESBURG, IL 61401

Pharmacy Comments

Contract Details

Approval Date

5/22/2023

Contract Begin Date

7/1/2023

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Diane L. McGrew, President
(309) 655-2850

Contract Pharmacy Representative

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

Signed By Date

4/12/2023

340B Drug Pricing Program Database