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LAKESIDE PHARMACY
CAH521350-00 LANGLADE HOSPITAL - HOTEL DIEU OF ST. JOSEPH OF ANTIGO WISCONSIN; DBA ASPIRUS LANGLADE HOSPITAL
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Covered Entity Details
Entity Name
LANGLADE HOSPITAL - HOTEL DIEU OF ST. JOSEPH OF ANTIGO WISCONSIN; DBA ASPIRUS LANGLADE HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521350-00
Entity Address
112 E. 5TH AVENUE
ANTIGO, WI 54409
Medicare Provider Number
521350
Participating Start Date
4/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
LAKESIDE PHARMACY
Pharmacy Address
536 5TH AVE
ANTIGO, WI 54409-2221
Pharmacy Comments
Contract Details
Approval Date
12/3/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/23/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patrick Tincher, Director of Finance/CFO
(715) 623-9215
Contract Pharmacy Representative
James Schofield, Co-Owner
(715) 623-2631
Signed By Date
10/12/2012
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