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HIGHLAND PARK CVS, L.L.C.
DSH140276 LOYOLA UNIVERSITY MEDICAL CENTER
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Covered Entity Details
Entity Name
LOYOLA UNIVERSITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140276
Entity Address
2160 SOUTH FIRST AVENUE
MAYWOOD, IL 60153
Medicare Provider Number
140276
Participating Start Date
4/1/2010
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 1965
7200 W. CERMAK RD.
NORTH RIVERSIDE, IL 60546
Pharmacy Comments
Contract Details
Approval Date
1/16/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/30/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Daniel Post, Executive Vice President
(708) 216-1670
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
1/16/2014
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