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FORWARD PHARMACY OF COTTAGE GROVE
DSH520089 Meriter Health Services
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Covered Entity Details
Entity Name
Meriter Health Services
Subdivision Name
UnityPoint Health-Meriter
Type
Disproportionate Share Hospital
340B ID
DSH520089
Entity Address
202 S Park St
Madison, WI 53715
Medicare Provider Number
520089
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
FORWARD PHARMACY OF COTTAGE GROVE
Pharmacy Address
429 W. COTTAGE GROVE RD
COTTAGE GROVE, WI 53527
Pharmacy Comments
Contract Details
Approval Date
10/14/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/25/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Beth Erdman, CFO
(608) 417-5800
Contract Pharmacy Representative
Forward Pharmacy of Columbus
Matt R. Mabie, Owner
(608) 347-5920
Signed By Date
10/14/2020
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