Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
CAH141310-00 Mendota Community Hospital d/b/a OSF Saint Paul Medical Center

Covered Entity Details

Entity Name

Mendota Community Hospital d/b/a OSF Saint Paul Medical Center

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH141310-00

Entity Address

1401 E. 12th St.
MENDOTA, IL 61342

Medicare Provider Number

141310

Participating Start Date

1/1/2011

Last Recertification Date

9/3/2024

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06897
1212 13TH AVENUE
MENDOTA, IL 61342

Pharmacy Comments

Contract Details

Approval Date

1/13/2014

Contract Begin Date

4/1/2014

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Lynn Klein, Administrator/CEO
(815) 539-7461 Ext: 3211

Contract Pharmacy Representative

CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298

Signed By Date

1/13/2014

340B Drug Pricing Program Database