Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
RRC140034-00 ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Covered Entity Details

Entity Name

ST. MARY'S HOSPITAL, CENTRALIA, ILLINOIS

Subdivision Name

Type

Rural Referral Center

340B ID

RRC140034-00

Entity Address

400 NORTH PLEASANT AVENUE
CENTRALIA, IL 62801

Medicare Provider Number

140034

Participating Start Date

4/1/2011

Last Recertification Date

9/19/2022

Entity Termination Date

7/1/2023

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06389
1022 W. MAIN ST.
SALEM, IL 62881

Pharmacy Comments

Contract Details

Approval Date

4/8/2016

Contract Begin Date

7/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

John Sigsbury, PRESIDENT
(618) 436-6525

Contract Pharmacy Representative

CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467

Signed By Date

4/8/2016

340B Drug Pricing Program Database