Contract Pharmacy Details

UNIVERSITY OF ILLINOIS MILE SQUARE PHARM
DSH140150 UNIVERSITY OF ILLINOIS HOSPITAL

Covered Entity Details

Entity Name

UNIVERSITY OF ILLINOIS HOSPITAL

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140150

Entity Address

1740 W Taylor St.
CHICAGO, IL 60612

Medicare Provider Number

140150

Participating Start Date

7/1/2009

Last Recertification Date

8/31/2024

Pharmacy Details

Pharmacy Name

UNIVERSITY OF ILLINOIS MILE SQUARE PHARM

Pharmacy Address

1220 S WOOD ST STE 1045
CHICAGO, IL 60608

Pharmacy Comments

Contract Details

Approval Date

1/14/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/22/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Bryan Becker, CEO
(312) 355-5706

Contract Pharmacy Representative

University of Illinois Mile Square
Rhondi Inman, Assistant Director
(312) 413-1767

Signed By Date

1/14/2014

340B Drug Pricing Program Database