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WAL-MART PHARMACY 10-1727
CAH521334-00 ThedaCare Medical Center - Waupaca
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Covered Entity Details
Entity Name
ThedaCare Medical Center - Waupaca
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521334-00
Entity Address
800 Riverside Drive
Waupaca, WI 54981
Medicare Provider Number
521334
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1727
Pharmacy Address
861 COUNTY HWY F
BERLIN, WI 54923
Pharmacy Comments
Contract Details
Approval Date
1/14/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/30/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kellie Diedrick, Vice President of New London and Waupaca Medical Centers
(920) 851-2024
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2022
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