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WAL-MART PHARMACY 10-1727
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
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
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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