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UNIV OF ILLINOIS WOOD STREET
DSH140150A UNIVERSITY OF ILLINOIS HOSPITAL
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Covered Entity Details
Entity Name
UNIVERSITY OF ILLINOIS HOSPITAL
Subdivision Name
UI HEALTH Ambulatory Care Clinics
Type
Disproportionate Share Hospital
340B ID
DSH140150A
Entity Address
1801 W. TAYLOR STREET
CHICAGO, IL 60612
Medicare Provider Number
140150
Outpatient Facility Provider Number
Participating Start Date
7/1/2009
Last Recertification Date
9/8/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
UNIV OF ILLINOIS WOOD STREET
Pharmacy Address
PCC PHARMA
840 S WOOD ST RM 163
M/C 884
CHICAGO, IL 60612-4325
Pharmacy Comments
Contract Details
Approval Date
9/1/2009
Contract Begin Date
9/1/2009
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
8/3/2009
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