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PHILLIPS ROCHE-A-CRI PHARMACY
CH050900 LA CLINICA DE LOS CAMPESINOS, INC.
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Covered Entity Details
Entity Name
LA CLINICA DE LOS CAMPESINOS, INC.
Subdivision Name
Noble Community Clinics - Wautoma
Type
HRSA-Funded Health Center
340B ID
CH050900
Entity Address
400 S. Townline Rd
WAUTOMA, WI 54982-1440
Grant Number
H80CS00713
Participating Start Date
4/1/1996
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
PHILLIPS ROCHE-A-CRI PHARMACY
Pharmacy Address
402 W LAKE ST
PO BOX 170
FRIENDSHIP, WI 53934
Pharmacy Comments
Contract Details
Approval Date
7/14/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Laura Waldvogel, CEO
(920) 787-9406
Contract Pharmacy Representative
Phillips Roche-A-Cri Pharmacy
Deena Kedrowski, Pharmacist
(608) 339-9080
Signed By Date
7/14/2018
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