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MORTON LTC
DSH520045 THEDACARE REGIONAL MEDICAL CENTER -
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Covered Entity Details
Entity Name
THEDACARE REGIONAL MEDICAL CENTER -
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520045
Entity Address
130 SECOND ST
NEENAH, WI 54956
Medicare Provider Number
520045
Participating Start Date
10/1/2024
Last Recertification Date
Entity Termination Date
1/1/2025
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
10/10/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
B Lynn Detterman, SVP, South Region
(920) 454-6380
Contract Pharmacy Representative
Morton Drug Co.
Dawn Wypiszynski@mortonltc.com, Vice President, Pharmacy Services
(920) 886-1109
Signed By Date
10/10/2024
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