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LUMICERA HEALTH SERVICES, LLC
CAH521327-00 WAUPUN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAUPUN MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521327-00
Entity Address
620 WEST BROWN STREET
WAUPUN, WI 53963
Medicare Provider Number
521327
Participating Start Date
9/30/2010
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
LUMICERA HEALTH SERVICES, LLC
Pharmacy Address
310 INTEGRITY DRIVE
MADISON, WI 53717-1499
Pharmacy Comments
Contract Details
Approval Date
7/8/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matt Kinsella, Regional Vice President of Finance
(608) 250-1194
Contract Pharmacy Representative
Lumicera
Eric Huckins, Manager
(608) 716-2667
Signed By Date
7/8/2022
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