Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140137 HSHS Holy Family Hospital, Inc.

Covered Entity Details

Entity Name

HSHS Holy Family Hospital, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140137

Entity Address

200 Healthcare Drive
Greenville, IL 62246

Medicare Provider Number

140137

Participating Start Date

7/1/2012

Last Recertification Date

8/27/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06926
12630 STATE ROUTE 143
HIGHLAND, IL 62249

Pharmacy Comments

Contract Details

Approval Date

7/15/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/15/2015
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Brian Nall, CEO
(618) 664-1230 Ext: 8410

Contract Pharmacy Representative

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

Signed By Date

7/15/2013

340B Drug Pricing Program Database