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CYSTIC FIBROSIS SERVICES, LLC
DSH040007 ST VINCENT INFIRMARY
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Covered Entity Details
Entity Name
ST VINCENT INFIRMARY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040007
Entity Address
#2 ST. VINCENT CIRCLE
ATTN: PHARMACY
LITTLE ROCK, AR 72205
Medicare Provider Number
040007
Participating Start Date
7/1/2003
Last Recertification Date
8/15/2024
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
10/8/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Polly Davenport, PRESIDENT
(501) 552-3933
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/15/2018
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