Covered Entity Details

CH05090C LA CLINICA DE LOS CAMPESINOS INC (Active) - information as of 5/10/2025 10:51:10 PM

Main Details

Name

LA CLINICA DE LOS CAMPESINOS INC

Subdivision Name

Noble Community Clinics - Friendship

Type

HRSA-Funded Health Center

Site ID

BPS-H80-022217

340B ID

CH05090C

Grant Number

H80CS00713

Additional Details

Current Program Status

Active

Registration Date

4/5/2023

Participating Start Date

7/1/2023

Participating Approval Date

4/5/2023

Last Recertification Date

2/13/2025

Contacts

Authorizing Official

La Clinica de los Campesinos
Laura Waldvogel, CEO
(920) 787-9406

Primary Contact

La Clinica De Los Campesinos, Inc.
Kellen J Dorff, Director of Pharmacy
(920) 647-8984

Addresses

Street Address

302 W Lake St
Friendship, WI 53934-9698

Billing Address

LA CLINICA DE LOS CAMPESINOS INC
PO Box 1440
WAUTOMA, WI 54982

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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	100080272,100237113	1790786929,1952027609

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.

Grantee Sites

340B ID	340B Status	SiteId	Name	Sub Name	Address	City	State
CH050900	Active	BPS-H80-003648	LA CLINICA DE LOS CAMPESINOS, INC.	Noble Community Clinics - Wautoma	400 S. Townline Rd	WAUTOMA	WI
CH05090A	Active	BPS-H80-035953	LA CLINICA DE LOS CAMPESINOS INC	Noble Community Clinics - Stevens Point Main Street	3125 Main Street	Stevens Point	WI
CH05090B	Active	BPS-H80-027168	LA CLINICA DE LOS CAMPESINOS INC	Noble Community Clinics - Stevens Point	3504 E Maria Dr	Stevens Point	WI
CH05090C	Active	BPS-H80-022217	LA CLINICA DE LOS CAMPESINOS INC	Noble Community Clinics - Friendship	302 W Lake St	Friendship	WI
CH05090D	Active	BPS-H80-037127	LA CLINICA DE LOS CAMPESINOS, INC.	Noble Community Clinics - Beaver Dam Spring Street	1701 N Spring St	Beaver Dam	WI

Grantee Sites Contract Pharmacies

340B ID	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Begin Date	Termination Date
CH050900	AURORA PHARMACY	900 E DIVISION ST		WAUTOMA	WI	54982-6944	07/01/2016	01/01/2017
CH050900	AURORA PHARMACY	900 E DIVISION ST		WAUTOMA	WI	54982-6944	07/01/2019
CH050900	DENNIS L HUNT PHARMACY	OMRO PHARMACY	KEN BRESSERS 328 E MAIN ST	OMRO	WI	54963-5496	10/01/2016	03/14/2017
CH050900	PHILLIPS ROCHE-A-CRI PHARMACY	402 W LAKE ST	PO BOX 170	FRIENDSHIP	WI	53934	10/01/2018	02/01/2022
CH050900	SHOPKO PHARMACY #2617	N2585 PLAZA RD		WAUTOMA	WI	54982	07/01/2016	02/01/2019
CH050900	SHOPKO PHARMACY #2619	220 W LINCOLN ST		ADAMS	WI	53910	07/01/2016	02/01/2019
CH050900	WAL-MART PHARMACY 10-1643	377 N ROLLING MEADOWS DR		FOND DU LAC	WI	54935	07/01/2016	12/18/2017
CH050900	WAL-MART PHARMACY 10-1727	861 COUNTY HWY F		BERLIN	WI	54923	07/01/2016	06/14/2023
CH050900	WAL-MART PHARMACY 10-1799	2950 NEW PINERY RD		PORTAGE	WI	53901	07/01/2016	02/28/2018
CH050900	WAL-MART PHARMACY 10-1828	250 CROSSROADS DRIVE		PLOVER	WI	54467	07/01/2016	06/14/2023
CH050900	WALGREEN CO.	DBA: WALGREENS # 01164	1203 W FOND DU LAC ST	RIPON	WI	54971-9289	07/01/2019	08/22/2019
CH050900	WALGREEN CO.	DBA: WALGREENS # 09009	3200 8TH STREET S	WISCONSIN RAPIDS	WI	54494-6563	07/01/2019	08/22/2019
CH050900	WALGREEN CO.	DBA: WALGREENS # 09699	925 W FULTON ST	WAUPACA	WI	54981-1479	07/01/2019	08/22/2019
CH050900	WALMART PHARMACY 10-5169	2252 NORTH 8TH STREET	SUITE A	ROGERS	AR	72756	07/01/2023	06/14/2023

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	Medicaid: Number	Delete	Recertification	100228370 (WI)		2/13/2025 7:02 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	2/13/2025 7:02 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		100237113	2/13/2025 7:02 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		WI	2/13/2025 7:02 AM
Details	Last Recertification Date	Update	Recertification	2/6/2024 12:15:43 PM	2/13/2025 7:02:48 AM	2/13/2025 7:02 AM
Details	Entity Subname	Update	Recertification	Family Health La Clinica- Friendship	Noble Community Clinics - Friendship	2/13/2025 7:02 AM
Contacts	Primary Contact	Update	Change Request	Peterson, Mike R Director of Pharmacy Family Health La Clinica 9207657011	Dorff, Kellen J Director of Pharmacy La Clinica De Los Campesinos, Inc. 9206478984	12/10/2024 4:15 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/17/2024 9:44 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		100228370	6/17/2024 9:44 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		WI	6/17/2024 9:44 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1952027609	6/17/2024 9:44 AM
Medicaid Billing	NPI: State	Insert	Change Request		WI	6/17/2024 9:44 AM
Details	Last Recertification Date	Update	Recertification		2/6/2024 12:15:43 PM	2/6/2024 12:15 PM
Details	State	Update		Approved	Active	7/1/2023 12:01 AM
Contacts	Primary Contact	Update	Profile Change Request	Peterson, Michael R Director of Pharmacy La Clinica De Los Campesinos 6085208333	Peterson, Mike R Director of Pharmacy Family Health La Clinica 9207657011	4/12/2023 12:58 PM
Contacts	Signed By	Insert	New Registration		Waldvogel, Laura CEO La Clinica de los Campesinos 9207879406	4/5/2023 12:39 PM
Details	340B ID	Update	New Registration		CH05090C	4/5/2023 12:39 PM
Dates	Participating Approval Date	Update	New Registration		4/5/2023 12:39:00 PM	4/5/2023 12:39 PM
Details	State	Update	New Registration	Pending	Approved	4/5/2023 12:39 PM
Dates	Signed By Date	Update	New Registration		4/5/2023 12:11:22 PM	4/5/2023 12:39 PM
Dates	Start Date	Update	New Registration		7/1/2023 12:00:00 AM	4/5/2023 12:39 PM
Addresses	Main Address	Insert	New Registration		302 W Lake St Friendship, WI 53934-9698	4/5/2023 9:27 AM
Addresses	Billing Address	Insert	New Registration		LA CLINICA DE LOS CAMPESINOS INC PO Box 1440 WAUTOMA, WI 54982	4/5/2023 9:27 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/5/2023 9:27 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		100080272	4/5/2023 9:27 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		WI	4/5/2023 9:27 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1790786929	4/5/2023 9:27 AM
Medicaid Billing	NPI: State	Insert	New Registration		WI	4/5/2023 9:27 AM
Contacts	Authorizing Official	Insert	New Registration		Waldvogel, Laura CEO La Clinica de los Campesinos 9207879406	4/5/2023 9:27 AM
Contacts	Primary Contact	Insert	New Registration		Peterson, Michael R Director of Pharmacy La Clinica De Los Campesinos 6085208333	4/5/2023 9:27 AM
Details	Assistance Received From Date	Insert	New Registration			4/5/2023 9:27 AM
Details	Assistance Received To Date	Insert	New Registration			4/5/2023 9:27 AM
Details	Last Recertification Date	Insert	New Registration			4/5/2023 9:27 AM
Details	Grant Number	Insert	New Registration		H80CS00713	4/5/2023 9:27 AM
Details	340B ID	Insert	New Registration			4/5/2023 9:27 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/5/2023 9:27 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/5/2023 9:27 AM
Details	Medicare Provider Number	Insert	New Registration			4/5/2023 9:27 AM
Details	Entity Name	Insert	New Registration		LA CLINICA DE LOS CAMPESINOS INC	4/5/2023 9:27 AM
Details	NOFO Number	Insert	New Registration			4/5/2023 9:27 AM
Details	Program Code	Insert	New Registration		CH	4/5/2023 9:27 AM
Details	Entity Subname	Insert	New Registration		Family Health La Clinica- Friendship	4/5/2023 9:27 AM
Dates	Participating Approval Date	Insert	New Registration			4/5/2023 9:27 AM
Details	State	Insert	New Registration		Pending	4/5/2023 9:27 AM
Dates	Registration Date	Insert	New Registration		4/5/2023 9:27:01 AM	4/5/2023 9:27 AM
Dates	Signed By Date	Insert	New Registration			4/5/2023 9:27 AM
Dates	Start Date	Insert	New Registration			4/5/2023 9:27 AM
Terminations	Termination Comments	Insert	New Registration			4/5/2023 9:27 AM
Terminations	Termination Date	Insert	New Registration			4/5/2023 9:27 AM
Terminations	Termination Effective Date	Insert	New Registration			4/5/2023 9:27 AM
Terminations	Termination Reason	Insert	New Registration			4/5/2023 9:27 AM

340B Drug Pricing Program Database