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SCHNUCKS PHARMACY #757
DSH140239 Javon Bea Hospital
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Covered Entity Details
Entity Name
Javon Bea Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140239
Entity Address
8201 E Riverside Blvd
Rockford, IL 61114
Medicare Provider Number
140239
Participating Start Date
1/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SCHNUCKS PHARMACY #757
Pharmacy Address
SCHNUCK MARKETS, INC.
2601 N. MULFORD RD.
ROCKFORD, IL 61114
Pharmacy Comments
Contract Details
Approval Date
8/20/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/27/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Henry Seybold, Senior Vice President / CFO
(815) 971-6796
Contract Pharmacy Representative
Schnuck's Pharmacy
David Chism, Director of Pharmacy
(314) 344-9636
Signed By Date
8/20/2015
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