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GUNDERSEN MOUNDVIEW PHARMACY
SCH520109-00 MILE BLUFF MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
MILE BLUFF MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520109-00
Entity Address
1050 DIVISION STREET
Mauston, WI 53948
Medicare Provider Number
520109
Participating Start Date
1/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
GUNDERSEN MOUNDVIEW PHARMACY
Pharmacy Address
402 W LAKE ST STE 1
FRIENDSHIP, WI 53934-9699
Pharmacy Comments
Contract Details
Approval Date
4/11/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dara Beth Bartels, Chief Executive Officer
(608) 847-2992
Contract Pharmacy Representative
Gundersen Health System
Loren Carrell, Director
(608) 775-6369
Signed By Date
4/11/2022
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