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MARSHFIELD CLINIC PHARMACY
SCH520011-00 LAKEVIEW MEDICAL CENTER OF RICE LAKE
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Covered Entity Details
Entity Name
LAKEVIEW MEDICAL CENTER OF RICE LAKE
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520011-00
Entity Address
1700 WEST STOUT STREET
RICE LAKE, WI 54868
Medicare Provider Number
520011
Participating Start Date
10/1/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
MARSHFIELD CLINIC PHARMACY
Pharmacy Address
1200 PORT ARTHUR RD STE 100
LADYSMITH, WI 54848
Pharmacy Comments
Contract Details
Approval Date
8/18/2021
Contract Begin Date
8/18/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bradley Groseth, Chief Administrative Officer
(715) 236-6131
Contract Pharmacy Representative
MMC
James Rubin, 340B Service Manager
(715) 532-2324
Signed By Date
8/9/2021
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