Contract Pharmacy Details

WALGREEN CO.
SCH520011-00 LAKEVIEW MEDICAL CENTER OF RICE LAKE

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS # 07966
849 WOODWARD AVE
CHIPPEWA FALLS, WI 54729-3362

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

Walgreens
Karl Meehan, VP Health System Programs
(847) 315-2663

Signed By Date

8/9/2021

340B Drug Pricing Program Database