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THEDA CARE PHARMACY
CAH521346-00 ThedaCare Medical Center Shawano, Inc.
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Covered Entity Details
Entity Name
ThedaCare Medical Center Shawano, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521346-00
Entity Address
100 County Road B
Shawano, WI 54166
Medicare Provider Number
521346
Participating Start Date
4/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
THEDA CARE PHARMACY
Pharmacy Address
100 COUNTY ROAD B
SHAWANO, WI 54166
Pharmacy Comments
Contract Details
Approval Date
1/16/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/22/2017
Ownership change
Contacts
Covered Entity Signing Official
Nancy Fugate, Director, Ancillary Services
(715) 526-7160
Contract Pharmacy Representative
Robert Probasco, Manager, Pharmacy Clinical Operations
(715) 584-8045
Signed By Date
1/16/2014
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