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PROVIDENT HOSPITAL OF COOK COUNTY
DSH140124AC JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY
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Covered Entity Details
Entity Name
JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY
Subdivision Name
Professional Building - Gynecology Tumor Clinic - Gynecology Tumor Clinic
Type
Disproportionate Share Hospital
340B ID
DSH140124AC
Entity Address
1950 West Polk Street
Chicago, IL 60612
Medicare Provider Number
140124
Outpatient Facility Provider Number
Participating Start Date
10/1/2022
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
PROVIDENT HOSPITAL OF COOK COUNTY
Pharmacy Address
ATTENTION PHARMACY DEPARTMENT
500 E 51ST ST
ROOM 2050
CHICAGO, IL 60615-2400
Pharmacy Comments
Contract Details
Approval Date
10/11/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Pamela Cassara, Chief Financial Officer
(312) 864-5507
Contract Pharmacy Representative
Cook County Health & Hospitals System
CaTanya Norwood, Senior Director of Pharmacy
(312) 864-2213
Signed By Date
10/11/2023
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