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COMMCARE PHARMACY-FTL, LLC
CAH141310-00 Mendota Community Hospital d/b/a OSF Saint Paul Medical Center
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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
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
10/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/10/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
Commcare Pharmacy
Avani Patel, Client Relations Manager
(561) 310-4324
Signed By Date
10/13/2016
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