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CHARLEY'S PHARMACY
DSH140012 OSF Saint Katharine Medical Center
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Covered Entity Details
Entity Name
OSF Saint Katharine Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140012
Entity Address
403 EAST FIRST STREET
DIXON, IL 61021
Medicare Provider Number
140012
Participating Start Date
7/1/2024
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
CHARLEY'S PHARMACY
Pharmacy Address
SNYDERS PHARMACY
FELKER PHARMACY
110 E MASON
POLO, IL 61064
Pharmacy Comments
Contract Details
Approval Date
7/13/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/2/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Anthony Evers, CFO
(815) 285-5521
Contract Pharmacy Representative
Kevin Fenwick, General Manager
(815) 973-1335
Signed By Date
7/13/2017
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