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Walmart Pharmacy 10-7611
SCH520011-00 LAKEVIEW MEDICAL CENTER OF RICE LAKE
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Covered Entity Details
Entity Name
LAKEVIEW MEDICAL CENTER OF RICE LAKE
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520011-00
Entity Address
1700 WEST STOUT STREET
RICE LAKE, WI 54868
Medicare Provider Number
520011
Participating Start Date
10/1/2023
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/2/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bradley Groseth, Chief Administrative Officer
(715) 236-6131
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/2/2024
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