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THREE LAKES PHARMACY
SCH520019-00 ASPIRUS RHINELANDER HOSPITAL
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Covered Entity Details
Entity Name
ASPIRUS RHINELANDER HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520019-00
Entity Address
2251 NORTH SHORE DRIVE
STE 100
RHINELANDER, WI 54501
Medicare Provider Number
520019
Participating Start Date
10/1/2024
Last Recertification Date
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
THREE LAKES PHARMACY
Pharmacy Address
PO BOX 437
1790 SUPERIOR ST
THREE LAKES, WI 54562
Pharmacy Comments
Contract Details
Approval Date
10/3/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sandra Anderson, Regional Vice President-Northern Region & Hospital President
(715) 361-2009
Contract Pharmacy Representative
Seth Moe, Owner
(715) 546-3266
Signed By Date
10/3/2016
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