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PETERSON PHARMACY
CAH521304-00 St. Joseph's Health Services, Inc. dba St. Joseph's Health Services-Gundersen Lutheran
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Covered Entity Details
Entity Name
St. Joseph's Health Services, Inc. dba St. Joseph's Health Services-Gundersen Lutheran
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521304-00
Entity Address
400 WATER AVE
HILLSBORO, WI 54634
Medicare Provider Number
521304
Participating Start Date
7/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
PETERSON PHARMACY
Pharmacy Address
727 WATER AVE
HILLSBORO, WI 54634-6229
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robin Nelson, CFO
(608) 489-8103
Contract Pharmacy Representative
Peterson Pharmacy
Matthew Mabie, Owner
(608) 347-5420
Signed By Date
4/14/2020
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