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DOC'S DRUGS OF FAIRBURY
DSH140186 RIVERSIDE MEDICAL CENTER
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Covered Entity Details
Entity Name
RIVERSIDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140186
Entity Address
350 N Wall Street
KANKAKEE, IL 60901
Medicare Provider Number
140186
Participating Start Date
1/1/2007
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
DOC'S DRUGS OF FAIRBURY
Pharmacy Address
902 E. OAK
FAIRBURY, IL 61739
Pharmacy Comments
Contract Details
Approval Date
4/18/2012
Contract Begin Date
4/18/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/6/2017
Ownership change
Contacts
Covered Entity Signing Official
Patricia K. Vilt, Vice President of Finance
(815) 935-7256
Contract Pharmacy Representative
Anthony Sartoris, President
(815) 458-6401 Ext: 12
Signed By Date
3/23/2012
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