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MALLATT'S PHARMACY AND COSTUMES #101
DSH520089 Meriter Health Services
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Covered Entity Details
Entity Name
Meriter Health Services
Subdivision Name
UnityPoint Health-Meriter
Type
Disproportionate Share Hospital
340B ID
DSH520089
Entity Address
202 S Park St
Madison, WI 53715
Medicare Provider Number
520089
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
MALLATT'S PHARMACY AND COSTUMES #101
Pharmacy Address
1255 WILLIAMSON ST.
MADISON, WI 53703
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
8/4/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Linda Hoff, CFO - Meriter Health Services
(608) 417-5811
Contract Pharmacy Representative
John M. Flint Jr., President
(608) 310-9922
Signed By Date
1/25/2013
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