Covered Entity Details

CAH521315-20 Mayo Clinic Health System Northland (Active) - information as of 4/25/2025 6:35:56 PM

Main Details

Name

Mayo Clinic Health System Northland

Subdivision Name

MCHS WI Rice Lake Clinic - Dermatology

Type

Critical Access Hospital

Rural

Yes

340B ID

CAH521315-20

Medicare Provider Number

521315

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/6/2023

Participating Start Date

1/1/2024

Participating Approval Date

10/11/2023

Last Recertification Date

8/13/2024

Contacts

Authorizing Official

Mayo Clinic
Michele Eberle, Vice Chair-Administration NWWI
(715) 568-6113

Primary Contact

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

Addresses

Street Address

331 S MAIN ST STE H
Rice Lake, WI 54868

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

Shipping Address 1

Mayo Clinic Health System Northland Barron Hospital Pharmacy
1222 East Woodland Avenue
Barron, WI 54812

Shipping Address 2

Mayo Clinic Health System Northland Barron Outpatient Pharmacy
1222 East Woodland Avenue
Barron, WI 54812

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
CAH521315-01	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Anesthesia	331 S MAIN STREET	RICE LAKE	WI	Active
CAH521315-02	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Otorhinolaryngology (ENT)	331 S MAIN STREET	RICE LAKE	WI	Active
CAH521315-03	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Orthopedic Surgery	331 S MAIN STREET	RICE LAKE	WI	Active
CAH521315-04	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Allergy & Immunology	331 S MAIN STREET	RICE LAKE	WI	Active
CAH521315-05	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Cardiac Diagnostic	331 S MAIN STREET	RICE LAKE	WI	Terminated
CAH521315-06	Child	CAH	Mayo Clinic Health System Northland	MCHS-NORTHLAND IN RICE LAKE - Gastroenterology & Hepatology	331 S MAIN STREET	RICE LAKE	WI	Active
CAH521315-07	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Physical Medicine and Rehabilitation	331 S Main St	Rice Lake	WI	Active
CAH521315-08	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Nutrition	331 S Main St	Rice Lake	WI	Terminated
CAH521315-09	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Palliative Medicine	331 S Main St	Rice Lake	WI	Terminated
CAH521315-10	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Nephrology	331 S Main St	Rice Lake	WI	Active
CAH521315-11	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Occupational Medicine	331 S Main St	Rice Lake	WI	Active
CAH521315-12	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Radiology	331 S Main St	Rice Lake	WI	Active
CAH521315-13	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Wound Care	331 S Main St	Rice Lake	WI	Active
CAH521315-14	Child	CAH	Mayo Clinic Health System Northland	MCHS Northland in Chetek - Radiology	220 Douglas Street	Chetek	WI	Terminated
CAH521315-15	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Pediatrics	331 S Main St	Rice Lake	WI	Active
CAH521315-16	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Obstetrics and Gynecology	331 S Main St	Rice Lake	WI	Active
CAH521315-17	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Chetek - Family Medicine	220 Douglas Street	Chetek	WI	Active
CAH521315-18	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Family Medicine	331 S Main St	Rice Lake	WI	Active
CAH521315-19	Child	CAH	Mayo Clinic Health System Northland	MCHS- Northland in Rice Lake - Urology	331 S Main St	Rice Lake	WI	Active
CAH521315-20	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Rice Lake Clinic - Dermatology	331 S MAIN ST STE H	Rice Lake	WI	Active
CAH521315-21	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Chetek Clinic - Anticoagulation	220 DOUGLAS ST	Chetek	WI	Active
CAH521315-22	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Rice Lake Clinic - Anticoagulation	331 S MAIN ST STE H	Rice Lake	WI	Active
CAH521315-23	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Rice Lake Clinic - Cardiovascular Disease	331 S MAIN ST STE H	Rice Lake	WI	Active
CAH521315-24	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Rice Lake Clinic - Psychiatry and Psychology	331 S MAIN ST STE H	Rice Lake	WI	Active
CAH521315-25	Child	CAH	Mayo Clinic Health System Northland	MCHS WI Rice Lake Clinic - Mobile Radiology	331 S MAIN STREET	RICE LAKE	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 1:49 PM
Details	Last Recertification Date	Update	Recertification		8/13/2024 8:00:12 AM	8/13/2024 8:00 AM
Details	State	Update		Approved	Active	1/1/2024 12:01 AM
Contacts	Signed By	Insert	New Registration		Eberle, Michele Vice Chair-Administration NWWI Mayo Clinic 7155686113	10/11/2023 12:11 PM
Details	340B ID	Update	New Registration		CAH521315-20	10/11/2023 12:11 PM
Details	Entity Name	Update	New Registration	MCHS NORTHLAND	Mayo Clinic Health System Northland	10/11/2023 12:11 PM
Details	Entity Subname	Update	New Registration	MCHS WI Rice Lake Clinic	MCHS WI Rice Lake Clinic - Dermatology	10/11/2023 12:11 PM
Dates	Participating Approval Date	Update	New Registration		10/11/2023 12:11:56 PM	10/11/2023 12:11 PM
Details	State	Update	New Registration	Pending	Approved	10/11/2023 12:11 PM
Dates	Signed By Date	Update	New Registration		10/10/2023 3:56:46 PM	10/11/2023 12:11 PM
Dates	Start Date	Update	New Registration		1/1/2024 12:00:00 AM	10/11/2023 12:11 PM
Addresses	Main Address	Insert	New Registration		331 S MAIN ST STE H Rice Lake, WI 54868	10/6/2023 6:31 PM
Addresses	Shipping Address	Insert	New Registration		Mayo Clinic Health System Northland Barron Hospital Pharmacy 1222 East Woodland Avenue Barron, WI 54812	10/6/2023 6:31 PM
Addresses	Shipping Address	Insert	New Registration		Mayo Clinic Health System Northland Barron Outpatient Pharmacy 1222 East Woodland Avenue Barron, WI 54812	10/6/2023 6:31 PM
Contacts	Authorizing Official	Insert	New Registration		Eberle, Michele Vice Chair-Administration NWWI Mayo Clinic 7155686113	10/6/2023 6:31 PM
Contacts	Primary Contact	Insert	New Registration		Buda, Alicia Operations Manager Mayo Clinic 5072933251	10/6/2023 6:31 PM
Details	Assistance Received From Date	Insert	New Registration			10/6/2023 6:31 PM
Details	Assistance Received To Date	Insert	New Registration			10/6/2023 6:31 PM
Details	Last Recertification Date	Insert	New Registration			10/6/2023 6:31 PM
Details	Grant Number	Insert	New Registration			10/6/2023 6:31 PM
Details	340B ID	Insert	New Registration			10/6/2023 6:31 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/6/2023 6:31 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/6/2023 6:31 PM
Details	Medicare Provider Number	Insert	New Registration		521315	10/6/2023 6:31 PM
Details	Entity Name	Insert	New Registration		MCHS NORTHLAND	10/6/2023 6:31 PM
Details	NOFO Number	Insert	New Registration			10/6/2023 6:31 PM
Details	Program Code	Insert	New Registration		CAH	10/6/2023 6:31 PM
Details	Entity Subname	Insert	New Registration		MCHS WI Rice Lake Clinic	10/6/2023 6:31 PM
Dates	Participating Approval Date	Insert	New Registration			10/6/2023 6:31 PM
Details	State	Insert	New Registration		Pending	10/6/2023 6:31 PM
Dates	Registration Date	Insert	New Registration		10/6/2023 6:31:36 PM	10/6/2023 6:31 PM
Dates	Signed By Date	Insert	New Registration			10/6/2023 6:31 PM
Dates	Start Date	Insert	New Registration			10/6/2023 6:31 PM
Terminations	Termination Comments	Insert	New Registration			10/6/2023 6:31 PM
Terminations	Termination Date	Insert	New Registration			10/6/2023 6:31 PM
Terminations	Termination Effective Date	Insert	New Registration			10/6/2023 6:31 PM
Terminations	Termination Reason	Insert	New Registration			10/6/2023 6:31 PM