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MEIJER STORES LIMITED PARTNERSHIP
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
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/18/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia K. Vilt, Chief Financial Officer
(815) 935-7542 Ext: 37219
Contract Pharmacy Representative
Meijer
Kevin Hurn, Dir, Pharmacy Procurement and New Business
(616) 791-5185
Signed By Date
4/12/2018
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