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HIGHLAND PARK CVS, L.L.C.
DSH140046 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140046
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06389
1022 W. MAIN ST.
SALEM, IL 62881
Pharmacy Comments
Contract Details
Approval Date
6/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/18/2023
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