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CYSTIC FIBROSIS SERVICES, LLC
DSH140250 SOUTH SUBURBAN HOSPITAL
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Covered Entity Details
Entity Name
SOUTH SUBURBAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140250
Entity Address
17800 Kedzie Ave
HAZELCREST, IL 60429
Medicare Provider Number
140250
Participating Start Date
10/1/2016
Last Recertification Date
11/9/2017
Entity Termination Date
7/1/2018
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/29/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Brian Kelly, VP Finance, Advocate Trinity Hospital
(708) 213-3004
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/29/2017
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