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MORTON LTC
CAH521334-00 ThedaCare Medical Center - Waupaca
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Covered Entity Details
Entity Name
ThedaCare Medical Center - Waupaca
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521334-00
Entity Address
800 Riverside Drive
Waupaca, WI 54981
Medicare Provider Number
521334
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
MORTON LTC
Pharmacy Address
DBA MORTON DRUG CO. INC.
201 E BELL ST
NEENAH, WI 54956-5096
Pharmacy Comments
Contract Details
Approval Date
7/10/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kellie Diedrick, Vice President of New London and Waupaca Medical Centers
(920) 851-2024
Contract Pharmacy Representative
Morton Drug Co.
Dawn Wypiszynski@mortonltc.com, Vice President, Pharmacy Services
(920) 886-1109
Signed By Date
7/10/2024
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