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WAL-MART PHARMACY 10-5090
CAH521346-00 ThedaCare Medical Center Shawano, Inc.
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Covered Entity Details
Entity Name
ThedaCare Medical Center Shawano, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521346-00
Entity Address
100 County Road B
Shawano, WI 54166
Medicare Provider Number
521346
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5090
Pharmacy Address
1415 LAWRENCE DR
DE PERE, WI 54115
Pharmacy Comments
Contract Details
Approval Date
1/17/2022
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
Julie Chikowski, VP
(715) 526-7200
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2022
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