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BELLIN HEALTH
RRC520049-00 BELLIN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BELLIN MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC520049-00
Entity Address
744 S WEBSTER AVENUE
GREEN BAY, WI 54301-3400
Medicare Provider Number
520049
Participating Start Date
1/1/2024
Last Recertification Date
9/6/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
BELLIN HEALTH
Pharmacy Address
BELLIN HEALTH PHARMACY
744 S WEBSTER AVE
GREEN BAY, WI 54301-3505
Pharmacy Comments
Contract Details
Approval Date
11/21/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sharla Baenen, Chief Operating Officer
(920) 433-7549
Contract Pharmacy Representative
Bellin Memorial Hospital Inc
Alar Laura, Director of Pharmacy
(920) 433-3635
Signed By Date
10/11/2023
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