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CAH521333-00 BLACK RIVER MEMORIAL HOSPITAL (Active)
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Main Details
Name
BLACK RIVER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH521333-00
Medicare Provider Number
521333
Additional Details
Current Program Status
Active
Registration Date
11/30/2010
Participating Start Date
1/1/2014
Participating Approval Date
12/1/2010
Last Recertification Date
8/22/2024
Contacts
Authorizing Official
Black River Memorial Hospital
Carl Selvick, President and CEO
(715) 284-1301
Primary Contact
Black River Memorial Hospital
Thane C Drier, Pharmacy Director
(715) 284-1323
Addresses
Street Address
711 WEST ADAMS STREET
BLACK RIVER FALLS, WI 54615
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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11/15/13 participating 1/1/11 thru 9/30/13, not participating 10/1/13 thru 12/31/13 due to failure to recertify, re-instated based on on-line registration submitted
11/15/2013
April 2025
April 2025
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