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VITAL RX, LLC
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
VITAL RX, LLC
Pharmacy Address
3110 W BELMONT AVE STE 1W
CHICAGO, IL 60618
Pharmacy Comments
Contract Details
Approval Date
7/18/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES WEIS, EXECUTIVE VP & CFO
(773) 257-6642
Contract Pharmacy Representative
Vital Rx, LLC
Rick Schumacher, Owner
(773) 862-1699
Signed By Date
7/18/2016
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