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COMMCARE PHARMACY-FTL, LLC
DSH140155 Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140155
Entity Address
500 West Court Street
Kankakee, IL 60901
Medicare Provider Number
140155
Participating Start Date
10/1/2014
Last Recertification Date
8/15/2024
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
4/16/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/3/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Melony Goodhand, Regional CFO
(815) 741-7236
Contract Pharmacy Representative
Kendell McManamy, VP of Operations
(954) 585-7943
Signed By Date
4/16/2015
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