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WAL-MART PHARMACY 10-2986
CAH521355-00 ThedaCare Medical Center Berlin, Inc.
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Covered Entity Details
Entity Name
ThedaCare Medical Center Berlin, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521355-00
Entity Address
225 MEMORIAL DRIVE
BERLIN, WI 54923
Medicare Provider Number
521355
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2986
Pharmacy Address
1155 WINNECONNE AVE
NEENAH, WI 54956
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
Tammy Bending, Vice President, Critical Access Hositals
(920) 361-5585
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2022
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