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SSM HEALTH PHARMACY
CAH521327-00 WAUPUN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAUPUN MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521327-00
Entity Address
620 WEST BROWN STREET
WAUPUN, WI 53963
Medicare Provider Number
521327
Participating Start Date
9/30/2010
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SSM HEALTH PHARMACY
Pharmacy Address
1211 FISH HATCHERY RD STE 300
MADISON, WI 53715
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DeAnn Thurmer, President/CNO
(920) 926-5409
Contract Pharmacy Representative
SSM Health
Eric Huckins, Pharmacy Manager
(608) 824-2682
Signed By Date
4/12/2019
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