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GENOA HEALTHCARE LLC
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
5710 N. BROADWAY STREET, SUITE P
CHICAGO, IL 60660-4302
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa M. Lukasick, CFO Illinois Region
(708) 216-5723
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
10/16/2023
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