Contract Pharmacy Details

AMERICAN DRUG STORES LLC
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER

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

AMERICAN DRUG STORES LLC

Pharmacy Address

DBA OSCO DRUG 3344
1220 S ASHLAND AVE
CHICAGO, IL 60608

Pharmacy Comments

Contract Details

Approval Date

4/17/2017

Contract Begin Date

7/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/4/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

CHARLES WEIS, EXECUTIVE VP & CFO
(773) 257-6642

Contract Pharmacy Representative

Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304

Signed By Date

4/17/2017

340B Drug Pricing Program Database