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ISLAND CITY APOTHECARY LTD
CAH521353-00 Cumberland Memorial Hospital, Inc.
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Covered Entity Details
Entity Name
Cumberland Memorial Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521353-00
Entity Address
1705 16th Ave
Cumberland, WI 54829
Medicare Provider Number
521353
Participating Start Date
1/1/2013
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
ISLAND CITY APOTHECARY LTD
Pharmacy Address
DBA THE APOTHECARY
1470 WEBB STREET
CUMBERLAND, WI 54829
Pharmacy Comments
Contract Details
Approval Date
1/7/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2018
Ownership change
Contacts
Covered Entity Signing Official
Michael Gutsch, Administrator
(715) 822-6194
Contract Pharmacy Representative
Thomas Goldsmith, Pharmacist
(715) 822-2424
Signed By Date
1/7/2014
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