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MEDI-PARK PHARMACY
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
MEDI-PARK PHARMACY
Pharmacy Address
420 NE GLEN OAK AVE STE 102
HILLCREST PLAZA
PEORIA, IL 61603-3171
Pharmacy Comments
Contract Details
Approval Date
4/14/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
Greg Puszkiewicz, Director Retail Pharmacy Services
(309) 624-8777
Signed By Date
4/14/2017
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