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CYSTIC FIBROSIS SERVICES, LLC
RRC140160-00 FREEPORT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
FREEPORT MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140160-00
Entity Address
1045 WEST STEPHENSON STREET
FREEPORT, IL 61032-4864
Medicare Provider Number
140160
Participating Start Date
1/1/2017
Last Recertification Date
11/16/2017
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
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael C. Clark, CFO
(815) 599-6361
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2018
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