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AGNESIAN HEALTHCARE INC.
CAH521327-00 WAUPUN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAUPUN MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521327-00
Entity Address
620 WEST BROWN STREET
WAUPUN, WI 53963
Medicare Provider Number
521327
Participating Start Date
9/30/2010
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
10/20/2011
Contract Begin Date
12/1/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steven Little, Executive V.P.
(920) 926-5402
Contract Pharmacy Representative
JANE HYDE, PRESIDENT
(920) 926-4964
Signed By Date
10/21/2010
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