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HIGHLAND PARK CVS, L.L.C.
CHC24098-14 SOUTHERN ILLINOIS UNIVERSITY
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS UNIVERSITY
Subdivision Name
SIU Center for Family Medicine-Taylorville
Type
HRSA-Funded Health Center
340B ID
CHC24098-14
Entity Address
303 E Bidwell St
Taylorville, IL 62568-1363
Grant Number
H80CS24098
Participating Start Date
4/1/2020
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06829
401 N. WEBSTER STREET
TAYLORVILLE, IL 62568
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
SIU Center for Family Medicine
Michael Black, CFO
(217) 747-6470
Signed By Date
7/15/2024
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