Covered Entity Details

CAH521359-00 Memorial Medical Center, Inc. DBA Tamarack Health Ashland Medical Center (Active) - information as of 6/24/2025 12:04:01 AM

Main Details

Name

Memorial Medical Center, Inc. DBA Tamarack Health Ashland Medical Center

Subdivision Name

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH521359-00

Medicare Provider Number

521359

Additional Details

Current Program Status

Active

Registration Date

1/12/2014

Participating Start Date

4/1/2014

Participating Approval Date

3/10/2014

Last Recertification Date

8/22/2024

Contacts

Authorizing Official

Memorial Medical Center, Inc.
Kent Dumonseau, Chief Financial Officer
(715) 685-5515

Primary Contact

Memorial Medical Center DBA Tamarack Health Ashland Medical Center
Amanda J Templer, Director of Pharmacy
(715) 685-5491

Addresses

Street Address

1615 Maple Lane
Ashland, WI 54806

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?
Yes

State	Medicaid Number	NPI Number
WI	11019500	1437179231

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300	SPRING	TX	77386	10/12/2020	01/01/2021	11/28/2023	12/13/2023
Contract Detail	WAL-MART PHARMACY 10-1672	2500 E LAKE SHORE DR	ASHLAND	WI	54806	10/12/2020	01/01/2021	11/28/2023	12/13/2023
Contract Detail	WAL-MART PHARMACY 10-5444	10305 COUNTRY CLUB ROAD	IRONWOOD	MI	49938	10/12/2020	01/01/2021	11/28/2023	12/13/2023
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100	ORLANDO	FL	32837	10/12/2020	01/01/2021	11/28/2023	12/13/2023

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
CAH521359-01	Child	CAH	Memorial Medical Center, Inc.	PSYCHIATRIC/PSYCHOLOGICAL SERVICES	1635 Maple Lane	ASHLAND	WI	Terminated
CAH521359-02	Child	CAH	Memorial Medical Center, Inc.	MEMORIAL MEDICAL CENTER - Ophthalmology Services of MMC	1615 MAPLE LN	ASHLAND	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/21/2023 2:54:05 PM	8/22/2024 3:11:04 PM	8/22/2024 3:11 PM
Contacts	Primary Contact	Update	Profile Change Request	Templer, Amanda J Director of Pharmacy Memorial Medical Center 7156855490	Templer, Amanda J Director of Pharmacy Memorial Medical Center DBA Tamarack Health Ashland Medical Center 7156855491	8/14/2024 10:24 AM
Details	Entity Name	Update	Change Request	Memorial Medical Center, Inc.	Memorial Medical Center, Inc. DBA Tamarack Health Ashland Medical Center	8/2/2024 1:58 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1801005210 (WI)		12/13/2023 3:07 PM
Details	Last Recertification Date	Update	Recertification	8/25/2022 10:08:47 AM	8/21/2023 2:54:05 PM	8/21/2023 2:54 PM
Details	Last Recertification Date	Update	Recertification	8/23/2021 11:21:30 AM	8/25/2022 10:08:47 AM	8/25/2022 10:08 AM
Details	Last Recertification Date	Update	Recertification	8/27/2020 7:15:11 AM	8/23/2021 11:21:30 AM	8/23/2021 11:21 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437179231	8/27/2020 7:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/27/2020 7:15 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1801005210	8/27/2020 7:15 AM
Medicaid Billing	NPI: State	Insert	Recertification		WI	8/27/2020 7:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1437179231 ( )		8/27/2020 7:15 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1801005210 ( )		8/27/2020 7:15 AM
Details	Last Recertification Date	Update	Recertification	8/21/2019 2:24:23 PM	8/27/2020 7:15:11 AM	8/27/2020 7:15 AM
Details	Last Recertification Date	Update	Recertification	8/15/2018 9:55:45 AM	8/21/2019 2:24:23 PM	8/21/2019 2:24 PM
Contacts	Primary Contact	Update	Change Request	Mattila, William Director of Pharmacy Memorial Medical Center 7156855490	Templer, Amanda J Director of Pharmacy Memorial Medical Center 7156855490	4/26/2019 1:35 PM
Details	Last Recertification Date	Update	Recertification	11/3/2017 6:18:36 AM	8/15/2018 9:55:45 AM	8/15/2018 9:55 AM
Details	Last Recertification Date	Update	Recertification	10/24/2017 1:02:41 PM	11/3/2017 6:18:36 AM	11/3/2017 6:18 AM
Details	Last Recertification Date	Update	Recertification	8/10/2016 12:00:00 AM	10/24/2017 1:02:41 PM	10/24/2017 1:02 PM
Contacts	Primary Contact	Update		Mattila, William Director of Pharmacy 7156855490	Mattila, William Director of Pharmacy Memorial Medical Center 7156855490	10/10/2017 10:27 AM
Contacts	Authorizing Official	Update		Dumonseau, Kent Chief Financial Officer 7156855515	Dumonseau, Kent Chief Financial Officer Memorial Medical Center, Inc. 7156855515	10/10/2017 10:19 AM
Contacts	Signed By	Update		Dumonseau, Kent Chief Financial Officer 7156855515	Dumonseau, Kent Chief Financial Officer Memorial Medical Center, Inc. 7156855515	10/10/2017 10:19 AM
Contacts	Authorizing Official	Insert			Dumonseau, Kent Chief Financial Officer 7156855515	7/27/2017 5:54 PM
Contacts	Signed By	Insert			Dumonseau, Kent Chief Financial Officer 7156855515	7/27/2017 5:54 PM
Contacts	Primary Contact	Insert			Mattila, William Director of Pharmacy 7156855490	7/27/2017 5:54 PM
Addresses	Main Address	Insert			1615 Maple Lane Ashland, WI 54806	6/14/2017 12:17 PM
Medicaid Billing	NPI: Number	Insert			1437179231	6/14/2017 12:16 PM
Medicaid Billing	NPI: Number	Insert			1801005210	6/14/2017 12:16 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/10/2016 12:00:00 AM	8/10/2016 12:03 PM
Details	Last Recertification Date	Update		8/13/2014 12:00:00 AM	8/5/2015 12:00:00 AM	8/5/2015 10:17 AM
Details	Last Recertification Date	Update			8/13/2014 12:00:00 AM	8/13/2014 5:41 PM
Dates	Participating Approval Date	Update			3/10/2014 12:00:00 AM	3/10/2014 5:52 PM
Details	State	Update		Pending	Active	3/10/2014 5:52 PM
Dates	Start Date	Update			4/1/2014 12:00:00 AM	3/10/2014 5:52 PM
Details	340B ID	Update		CAH521359-01	CAH521359-00	3/10/2014 12:40 PM
Details	340B ID	Update		ONLINE_REG	CAH521359-01	2/11/2014 9:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	1/12/2014 10:08 PM
Medicaid Billing	Medicaid: Number	Insert			11019500	1/12/2014 10:08 PM
Medicaid Billing	Medicaid: State	Insert			WI	1/12/2014 10:08 PM
Details	Last Recertification Date	Insert				1/12/2014 10:08 PM
Details	Grant Number	Insert				1/12/2014 10:08 PM
Details	340B ID	Insert			ONLINE_REG	1/12/2014 10:08 PM
Details	Is Authorizing Official EHB Data	Insert				1/12/2014 10:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert				1/12/2014 10:08 PM
Details	Medicare Provider Number	Insert			521359	1/12/2014 10:08 PM
Details	Entity Name	Insert			Memorial Medical Center, Inc.	1/12/2014 10:08 PM
Details	Program Code	Insert			CAH	1/12/2014 10:08 PM
Details	Entity Subname	Insert				1/12/2014 10:08 PM
Dates	Participating Approval Date	Insert				1/12/2014 10:08 PM
Details	State	Insert			Pending	1/12/2014 10:08 PM
Dates	Registration Date	Insert			1/12/2014 12:00:00 AM	1/12/2014 10:08 PM
Dates	Signed By Date	Insert			1/12/2014 12:00:00 AM	1/12/2014 10:08 PM
Dates	Start Date	Insert				1/12/2014 10:08 PM
Terminations	Termination Comments	Insert				1/12/2014 10:08 PM
Terminations	Termination Date	Insert				1/12/2014 10:08 PM
Terminations	Termination Effective Date	Insert				1/12/2014 10:08 PM
Terminations	Termination Reason	Insert				1/12/2014 10:08 PM