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THE CARLE FOUNDATION HOSPITAL
DSH140209 METHODIST MEDICAL CENTER OF ILLINOIS
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Covered Entity Details
Entity Name
METHODIST MEDICAL CENTER OF ILLINOIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140209
Entity Address
221 NE GLEN OAK AVE.
PEORIA, IL 61636
Medicare Provider Number
140209
Participating Start Date
10/1/2006
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
THE CARLE FOUNDATION HOSPITAL
Pharmacy Address
DBA CARLE HOME INFUSION PHARMACY
221 N BROADWAY AVE
SUITE 100
URBANA, IL 61801-2747
Pharmacy Comments
Contract Details
Approval Date
4/19/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Keith E. Knepp, CEO
(309) 671-2528
Contract Pharmacy Representative
The Carle Foundation Hospital
Benjamin Bodznick, Director- Pharmacy Services
(217) 904-7001
Signed By Date
4/19/2023
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