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WAL-MART PHARMACY 10-1828
DSH520037 MARSHFIELD MEDICAL CENTER
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Covered Entity Details
Entity Name
MARSHFIELD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520037
Entity Address
611 St Joseph Avenue
MARSHFIELD, WI 54449
Medicare Provider Number
520037
Participating Start Date
1/1/2024
Last Recertification Date
9/5/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1828
Pharmacy Address
250 CROSSROADS DRIVE
PLOVER, WI 54467
Pharmacy Comments
Contract Details
Approval Date
10/17/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Robert Chaloner, President
(715) 387-7855
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
10/13/2023
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