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WALGREEN CO.
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
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #11857
10489 STATE ROAD 27
HAYWARD, WI 54843
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
5/22/2019
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