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MERCY HEALTH SYSTEM
CAH521357-00 Mercy Walworth Hospital
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Covered Entity Details
Entity Name
Mercy Walworth Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521357-00
Entity Address
N2950 State Road 67
Lake Geneva, WI 53147-2655
Medicare Provider Number
521357
Participating Start Date
1/1/2014
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
MERCY HEALTH SYSTEM
Pharmacy Address
N2950 STATE ROAD 67
MERCY WALWORTH PHARMACY
LAKE GENEVA, WI 53147-2655
Pharmacy Comments
Contract Details
Approval Date
1/11/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/6/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Cook, Senior VP / CFO
(608) 756-6642
Contract Pharmacy Representative
Mercy Health System
Don Janczak, Director of Pharmacy
(608) 756-6664
Signed By Date
1/11/2019
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