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FORWARD PHARMACY OF COLUMBUS
CAH521338-00 PRAIRIE RIDGE HEALTH, INC.
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Covered Entity Details
Entity Name
PRAIRIE RIDGE HEALTH, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521338-00
Entity Address
1515 PARK AVENUE
COLUMBUS, WI 53925-1618
Medicare Provider Number
521338
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
FORWARD PHARMACY OF COLUMBUS
Pharmacy Address
100 S LUDINGTON ST
COLUMBUS, WI 53925-1516
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Melissa S. Mangan, Vice President of Finance/Chief Financial Officer
(920) 623-1369
Contract Pharmacy Representative
Forward Pharmacy of Columbus
Matt R. Mabie, Owner
(608) 347-5920
Signed By Date
7/15/2020
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