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HIGHLAND PARK CVS, L.L.C.
RRC140135-00 Decatur Memorial Hospital
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Covered Entity Details
Entity Name
Decatur Memorial Hospital
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140135-00
Entity Address
2300 N. Edward St.
Decatur, IL 62526
Medicare Provider Number
140135
Participating Start Date
7/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04857
570 N. FAIRVIEW AVE.
DECATUR, IL 62522
Pharmacy Comments
Contract Details
Approval Date
7/6/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/16/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Deborah L. Bragg, Senior VP, Finance
(217) 876-2107
Contract Pharmacy Representative
CVS Health
Jaclyn Parfitt, 340B Operations Manager
(401) 770-6467
Signed By Date
7/6/2016
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