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HIGHLAND PARK CVS, L.L.C.
DSH140186 RIVERSIDE MEDICAL CENTER
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Covered Entity Details
Entity Name
RIVERSIDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140186
Entity Address
350 N Wall Street
KANKAKEE, IL 60901
Medicare Provider Number
140186
Participating Start Date
1/1/2007
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY #10624
902 E OAK ST.
FAIRBURY, IL 61739
Pharmacy Comments
Contract Details
Approval Date
11/6/2017
Contract Begin Date
11/6/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/8/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia K. Vilt, Vice President of Finance
(815) 935-7256
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
11/6/2017
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