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WISCONSIN CVS PHARMACY, L.L.C.
CAH521357-00 Mercy Walworth Hospital
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Covered Entity Details
Entity Name
Mercy Walworth Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521357-00
Entity Address
N2950 State Road 67
Lake Geneva, WI 53147-2655
Medicare Provider Number
521357
Participating Start Date
1/1/2014
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WISCONSIN CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 16257
2017 HUMES RD
JANESVILLE, WI 53545
Pharmacy Comments
Contract Details
Approval Date
1/15/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Todd Anderson, Vice President Finance
(815) 971-6738
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2022
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