Covered Entity Details

CAH521305-03 MCHS-FRANCISCAN SPARTA (Active) - information as of 4/28/2025 1:48:53 AM

Main Details

Name

MCHS-FRANCISCAN SPARTA

Subdivision Name

Arcadia Clinic - Obstetrics and Gynecology

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH521305-03

Medicare Provider Number

521305

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/8/2024

Participating Start Date

1/1/2025

Participating Approval Date

10/17/2024

Last Recertification Date

Contacts

Authorizing Official

Mayo Clinic Health System
Tanner Holst, Regional Chair-Administration SWWI
(608) 392-9705

Primary Contact

Mayo Clinic Health System
Matt Lemin, Program Manager
(507) 293-3853

Addresses

Street Address

895 Dettloff Dr
Arcadia, WI 54612

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
No

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH521305-01	Child	CAH	Mayo Clinic Health System-Franciscan Healthcare Sparta	Sparta Clinic	310 West Main Street	Sparta	WI	Terminated
CAH521305-02	Child	CAH	MCHS-FRANCISCAN SPARTA	Prairie du Chien Clinic - Obstetrics and Gynecology	800 E Blackhawk Ave	Prairie du Chien	WI	Active
CAH521305-03	Child	CAH	MCHS-FRANCISCAN SPARTA	Arcadia Clinic - Obstetrics and Gynecology	895 Dettloff Dr	Arcadia	WI	Active
CAH521305-04	Child	CAH	MCHS-FRANCISCAN SPARTA	Arcadia Clinic - Family Medicine	895 Dettloff Dr	Arcadia	WI	Active
CAH521305-05	Child	CAH	MCHS-FRANCISCAN SPARTA	Arcadia Clinic - Anticoagulation	895 Dettloff Dr	Arcadia	WI	Active
CAH521305-06	Child	CAH	MCHS-FRANCISCAN SPARTA	Prairie du Chien Clinic - Family Medicine	800 E Blackhawk Ave	Prairie du Chien	WI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Group Change Request	Buda, Alicia Operations Manager Mayo Clinic 5072933251	Lemin, Matt Program Manager Mayo Clinic Health System 5072933853	4/3/2025 2:09 PM
Details	State	Update		Approved	Active	1/1/2025 12:01 AM
Contacts	Signed By	Insert	New Registration		Holst, Tanner Regional Chair-Administration SWWI Mayo Clinic Health System 6083929705	10/17/2024 7:26 AM
Details	340B ID	Update	New Registration		CAH521305-03	10/17/2024 7:26 AM
Details	Entity Subname	Update	New Registration	Arcadia Clinic	Arcadia Clinic - Obstetrics and Gynecology	10/17/2024 7:26 AM
Dates	Participating Approval Date	Update	New Registration		10/17/2024 7:26:48 AM	10/17/2024 7:26 AM
Details	State	Update	New Registration	Pending	Approved	10/17/2024 7:26 AM
Dates	Signed By Date	Update	New Registration		10/10/2024 12:11:33 PM	10/17/2024 7:26 AM
Dates	Start Date	Update	New Registration		1/1/2025 12:00:00 AM	10/17/2024 7:26 AM
Addresses	Main Address	Insert	New Registration		895 Dettloff Dr Arcadia, WI 54612	10/8/2024 1:52 PM
Contacts	Primary Contact	Insert	New Registration		Buda, Alicia Operations Manager Mayo Clinic 5072933251	10/8/2024 1:52 PM
Contacts	Authorizing Official	Insert	New Registration		Holst, Tanner Regional Chair-Administration SWWI Mayo Clinic Health System 6083929705	10/8/2024 1:52 PM
Details	Assistance Received From Date	Insert	New Registration			10/8/2024 1:52 PM
Details	Assistance Received To Date	Insert	New Registration			10/8/2024 1:52 PM
Details	Last Recertification Date	Insert	New Registration			10/8/2024 1:52 PM
Details	Grant Number	Insert	New Registration			10/8/2024 1:52 PM
Details	340B ID	Insert	New Registration			10/8/2024 1:52 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/8/2024 1:52 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/8/2024 1:52 PM
Details	Medicare Provider Number	Insert	New Registration		521305	10/8/2024 1:52 PM
Details	Entity Name	Insert	New Registration		MCHS-FRANCISCAN SPARTA	10/8/2024 1:52 PM
Details	NOFO Number	Insert	New Registration			10/8/2024 1:52 PM
Details	Program Code	Insert	New Registration		CAH	10/8/2024 1:52 PM
Details	Entity Subname	Insert	New Registration		Arcadia Clinic	10/8/2024 1:52 PM
Dates	Participating Approval Date	Insert	New Registration			10/8/2024 1:52 PM
Details	State	Insert	New Registration		Pending	10/8/2024 1:52 PM
Dates	Registration Date	Insert	New Registration		10/8/2024 1:52:31 PM	10/8/2024 1:52 PM
Dates	Signed By Date	Insert	New Registration			10/8/2024 1:52 PM
Dates	Start Date	Insert	New Registration			10/8/2024 1:52 PM
Terminations	Termination Comments	Insert	New Registration			10/8/2024 1:52 PM
Terminations	Termination Date	Insert	New Registration			10/8/2024 1:52 PM
Terminations	Termination Effective Date	Insert	New Registration			10/8/2024 1:52 PM
Terminations	Termination Reason	Insert	New Registration			10/8/2024 1:52 PM