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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09009
3200 8TH STREET S
WISCONSIN RAPIDS, WI 54494-6563
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
8/22/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Laura Waldvogel, CEO
(920) 787-9406
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/12/2019
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