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HSHS PHARMACY #102
CAH521310-00 ST Clare Memorial Hospital Inc.
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Covered Entity Details
Entity Name
ST Clare Memorial Hospital Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521310-00
Entity Address
855 S Main St
Oconto Falls, WI 54154
Medicare Provider Number
521310
Participating Start Date
1/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
HSHS PHARMACY #102
Pharmacy Address
ST. CLARE MEMORIAL HOSPITAL
117 N MCKENZIE ST
PO BOX 558
GILLETT, WI 54124
Pharmacy Comments
Contract Details
Approval Date
3/11/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/7/2016
Agreement registered in error
Contacts
Covered Entity Signing Official
Daniel Degroot, CEO
(920) 846-3444 Ext: 1203
Contract Pharmacy Representative
Michele Miller, CFO
(920) 846-3444
Signed By Date
1/11/2013
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