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PRESENCE HOSPITALS PRV
DSH140174 PRESENCE MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
PRESENCE MERCY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140174
Entity Address
1325 NORTH HIGHLAND AVENUE, ATTN: ADMINISTRATION
AURORA, IL 60506
Medicare Provider Number
140174
Participating Start Date
4/1/2010
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
PRESENCE HOSPITALS PRV
Pharmacy Address
DBA MERCY PROFESSIONAL BUILDING PHARMACY
1325 N HIGHLAND AVE STE 101
AURORA, IL 60506-1449
Pharmacy Comments
Contract Details
Approval Date
4/8/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kevin Larkin, Regional CFO
(630) 801-2729
Contract Pharmacy Representative
Nicholas Zambetti, Manager Retail Pharmacy
(630) 801-5733
Signed By Date
4/8/2015
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