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Trinity Health Pharmacy Services, LLC
RRC150012-00 ST. JOSEPHS REG MED CENTER S. BEND
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Covered Entity Details
Entity Name
ST. JOSEPHS REG MED CENTER S. BEND
Subdivision Name
Type
Rural Referral Center
340B ID
RRC150012-00
Entity Address
5215 HOLY CROSS PARKWAY
MISHAWAKA, IN 46545
Medicare Provider Number
150012
Participating Start Date
7/1/2023
Last Recertification Date
8/18/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
Trinity Health Pharmacy Services, LLC
Pharmacy Address
12279 Bluffton Road
Fort Waye, IN 46809
Pharmacy Comments
Contract Details
Approval Date
6/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723
Contract Pharmacy Representative
TRINITY HEALTH
ZACHARY ROBERTS, DIRECTOR OF SPECIALTY PHARMACY
(734) 343-7606
Signed By Date
6/1/2023
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