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DEGEN BERGLUND PHARMACY
DSH520087 Gundersen Lutheran Medical Center, Inc.
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Covered Entity Details
Entity Name
Gundersen Lutheran Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520087
Entity Address
1900 South Ave
La Crosse, WI 54601
Medicare Provider Number
520087
Participating Start Date
7/1/2012
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
DEGEN BERGLUND PHARMACY
Pharmacy Address
2511 GREEN BAY ST
LA CROSSE, WI 54601
Pharmacy Comments
Contract Details
Approval Date
8/24/2012
Contract Begin Date
8/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2019
Ownership change
Contacts
Covered Entity Signing Official
Gordon T. Edwards, CFO
(608) 782-7300
Contract Pharmacy Representative
Tamara M. Dutton, CEO
(608) 775-8526
Signed By Date
8/8/2012
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