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CRIVITZ PHARMACY
SCH230055-00 Marshfield Medical Center - Dickinson
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Covered Entity Details
Entity Name
Marshfield Medical Center - Dickinson
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230055-00
Entity Address
1721 S. Stephenson Avenue
Iron Mountain, MI 49801
Medicare Provider Number
230055
Participating Start Date
7/1/2017
Last Recertification Date
8/30/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
CRIVITZ PHARMACY
Pharmacy Address
FLORENCE PRESCRIPTION SERVICES RDS
1010 OLIVE AVENUE
FLORENCE, WI 54121
Pharmacy Comments
Contract Details
Approval Date
6/23/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/31/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
Susan Hadley, Director of Nursing
(906) 776-5596
Contract Pharmacy Representative
Ezra Gruszynski, President
(715) 854-7425
Signed By Date
6/23/2017
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