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HIGHLAND PARK CVS, L.L.C.
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
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08733
3552 W GRAND
CHICAGO, IL 60651
Pharmacy Comments
Contract Details
Approval Date
7/26/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/18/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
Suzanne Lambert, VP Patient Care Services/CNO
(312) 770-2107
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
7/26/2013
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