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AGNESIAN HEALTHCARE INC.
SCH520088-00 SSM HEALTH ST AGNES HOSPITAL - FOND DU LAC
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Covered Entity Details
Entity Name
SSM HEALTH ST AGNES HOSPITAL - FOND DU LAC
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520088-00
Entity Address
430 EAST DIVISION STREET
FOND DU LAC, WI 54935
Medicare Provider Number
520088
Participating Start Date
10/1/2023
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
AGNESIAN HEALTHCARE INC.
Pharmacy Address
SSM HEALTH PHARMACY
904 W MAIN ST
WAUPUN, WI 53963
Pharmacy Comments
4/13/11 CHANGED ADDR (WAS 910 W. MAIN STREET)
Contract Details
Approval Date
10/12/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Ownership change
Contacts
Covered Entity Signing Official
Matt Kinsella, Regional Vice President of Finance
(608) 250-1194
Contract Pharmacy Representative
SSM Health
Nicole Maywright, Phamaccy Team Leader
(636) 669-2223
Signed By Date
10/12/2023
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