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SAINT JOSEPH'S HOSP OTPA PHARM
CAH521358-00 DOOR COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DOOR COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521358-00
Entity Address
323 SOUTH 18TH AVENUE
STURGEON BAY, WI 54235
Medicare Provider Number
521358
Participating Start Date
7/1/2011
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
SAINT JOSEPH'S HOSP OTPA PHARM
Pharmacy Address
DBA ASCENSION WISCONSIN PHARMACY #701
1901 WESTWOOD CENTER BLVD
WAUSAU, WI 54401
Pharmacy Comments
Contract Details
Approval Date
3/15/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/24/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jody Boes, Vice President
(920) 746-3601
Contract Pharmacy Representative
Vanessa Freitag, Director of Pharmacy
(715) 389-5302
Signed By Date
1/15/2013
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