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WAL-MART PHARMACY 10-3505
SCH520109-00 MILE BLUFF MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
MILE BLUFF MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520109-00
Entity Address
1050 DIVISION STREET
Mauston, WI 53948
Medicare Provider Number
520109
Participating Start Date
1/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3505
Pharmacy Address
130 COMMERCE STREET
WISCONSIN DELLS, WI 53965
Pharmacy Comments
Contract Details
Approval Date
1/7/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Michael O'Keefe, Chief Executive Officer
(608) 847-2998
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/7/2020
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