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WALGREEN CO.
CAH521303-00 ThedaCare Medical Center Wild Rose, Inc.
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Covered Entity Details
Entity Name
ThedaCare Medical Center Wild Rose, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521303-00
Entity Address
601 GROVE AVENUE
WILD ROSE, WI 54984
Medicare Provider Number
521303
Participating Start Date
4/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 09699
925 W FULTON ST
WAUPACA, WI 54981-1479
Pharmacy Comments
Contract Details
Approval Date
7/15/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Bending, Vice President, Critical Access Hositals
(920) 361-5585
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
7/15/2021
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