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SHOPKO PHARMACY #2014
CAH521338-00 PRAIRIE RIDGE HEALTH, INC.
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Covered Entity Details
Entity Name
PRAIRIE RIDGE HEALTH, INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521338-00
Entity Address
1515 PARK AVENUE
COLUMBUS, WI 53925-1618
Medicare Provider Number
521338
Participating Start Date
1/1/2014
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #2014
Pharmacy Address
822 PARK AVE
BEAVER DAM, WI 53916-2292
Pharmacy Comments
Contract Details
Approval Date
7/6/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/1/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
Phillip G. Roberts, Vice President and CFO
(920) 623-1368
Contract Pharmacy Representative
Lori Neumann, Manager
(920) 429-5725
Signed By Date
7/6/2017
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