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HIGHLAND PARK CVS, L.L.C.
SCH140167-00 IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
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Covered Entity Details
Entity Name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140167-00
Entity Address
200 E FAIRMAN AVE
WATSEKA, IL 60970-1644
Medicare Provider Number
140167
Participating Start Date
4/1/2014
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY #10627
720 S CRESCENT ST
GILMAN, IL 60938
Pharmacy Comments
Contract Details
Approval Date
4/9/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Lori Yelenick, CFO
(815) 432-7929
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
4/9/2018
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