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LITTLE VILLAGE PHARMACY, INC
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
LITTLE VILLAGE PHARMACY, INC
Pharmacy Address
DBA PROPACK PHARMACY
2600 S 25TH AVE STE 110
BROADVIEW, IL 60155
Pharmacy Comments
Contract Details
Approval Date
4/4/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHARLES WEIS, EXECUTIVE VP & CFO
(773) 257-6642
Contract Pharmacy Representative
MITESH PATEL, PHARMACY MANAGER
(847) 912-3201
Signed By Date
4/4/2014
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