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MERCY HOSPITAL & MEDICAL CENTER
DSH140158G MERCY HOSPITAL AND MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY HOSPITAL AND MEDICAL CENTER
Subdivision Name
ASHLAND
Type
Disproportionate Share Hospital
340B ID
DSH140158G
Entity Address
3316 S. ASHLAND AVENUE
CHICAGO, IL 60608
Medicare Provider Number
140158
Outpatient Facility Provider Number
Participating Start Date
7/1/2004
Last Recertification Date
8/6/2015
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
MERCY HOSPITAL & MEDICAL CENTER
Pharmacy Address
DEPARTMENT OF PHARMACY SERVICES
2525 S. MICHIGAN AVENUE
CHICAGO, IL 60616-2477
Pharmacy Comments
Contract Details
Approval Date
8/1/2005
Contract Begin Date
8/1/2005
Carve-In Effective Date
Contract Comments
4/23/08 ADMIN CORRECTION 340B ID # CHANGED (WAS DSH60616G)
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
7/27/2005
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