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AGNESIAN HEALTHCARE INC.
CAH521327-03 WAUPUN MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAUPUN MEMORIAL HOSPITAL
Subdivision Name
Beaver Dam Dialysis
Type
Critical Access Hospital
340B ID
CAH521327-03
Entity Address
2100 Kellom Rd Unit A
Beaver Dam, WI 53916
Medicare Provider Number
521327
Outpatient Facility Provider Number
523531
Participating Start Date
4/1/2013
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
AGNESIAN HEALTHCARE INC.
Pharmacy Address
SSM HEALTH PRESCRIPTION CENTER
421 CAMELOT DRIVE
FOND DU LAC, WI 54935
Pharmacy Comments
Contract Details
Approval Date
10/15/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bonnie Schmitz, CFO
(920) 926-4480
Contract Pharmacy Representative
Barbara Knutzen, AHE Chief Operating Officer
(920) 926-5407
Signed By Date
10/15/2015
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