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MEDI-PARK PHARMACY
RRC140110-00 OTTAWA REGIONAL HOSPITAL & HEALTHCAR
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Covered Entity Details
Entity Name
OTTAWA REGIONAL HOSPITAL & HEALTHCAR
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140110-00
Entity Address
1100 EAST NORRIS DRIVE
OTTAWA, IL 61350
Medicare Provider Number
140110
Participating Start Date
7/1/2015
Last Recertification Date
9/5/2019
Entity Termination Date
7/1/2020
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
4/14/2020
Covered Entity Terminated
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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