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MARSHFIELD CLINIC PHARMACY
DSH520011 LAKEVIEW MEDICAL CENTER
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Covered Entity Details
Entity Name
LAKEVIEW MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520011
Entity Address
1700 WEST STOUT STREET
RICE LAKE, WI 54868
Medicare Provider Number
520011
Participating Start Date
3/15/2022
Last Recertification Date
8/29/2022
Entity Termination Date
10/1/2023
Pharmacy Details
Pharmacy Name
MARSHFIELD CLINIC PHARMACY
Pharmacy Address
1700 W STOUT ST
RICE LAKE, WI 54868-5000
Pharmacy Comments
Contract Details
Approval Date
5/31/2019
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Tarese Lynn Dubiel, CFO
(715) 214-8707
Contract Pharmacy Representative
Marshfield Medical Center
Sarah Elizabeth Rall, Director of Pharmacy
(715) 389-3173
Signed By Date
5/22/2019
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