Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
DSH140250 SOUTH SUBURBAN HOSPITAL

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

HIGHLAND PARK CVS, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 07166
250 W. 144TH ST.
RIVERDALE, IL 60827

Pharmacy Comments

Contract Details

Approval Date

7/18/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/15/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Brian Kelly, VP Finance, Advocate Trinity Hospital
(708) 213-3004

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/18/2017

340B Drug Pricing Program Database