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GUNDERSEN LONG TERM CARE 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
GUNDERSEN LONG TERM CARE PHARMACY
Pharmacy Address
505 KING ST
STE 154
LA CROSSE, WI 54601-4062
Pharmacy Comments
Contract Details
Approval Date
4/11/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Laurie A. Hurwitz, Executive Director of Revenue Cycle
(608) 775-4370
Contract Pharmacy Representative
Gundersen Health System
Loren Carrell, Director
(608) 775-6369
Signed By Date
4/11/2017
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