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PRESENCE NAZARETH FAMILY CENTER
DSH140180 Presence Saints Mary and Elizabeth Medical Center
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Covered Entity Details
Entity Name
Presence Saints Mary and Elizabeth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140180
Entity Address
2233 WEST DIVISION STREET
CHICAGO, IL 60622
Medicare Provider Number
140180
Participating Start Date
7/1/2003
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PRESENCE NAZARETH FAMILY CENTER
Pharmacy Address
PHARMACY
1127 N. OAKLEY BLVD
CHICAGO, IL 60622
Pharmacy Comments
Contract Details
Approval Date
7/1/2004
Contract Begin Date
7/1/2004
Carve-In Effective Date
Contract Comments
4/21/08 ADMIN CORRECTION 340B ID # CHANGED (WAS DSH60622)
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
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