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SHOPKO PHARMACY #789
CAH521334-00 ThedaCare Medical Center - Waupaca
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Covered Entity Details
Entity Name
ThedaCare Medical Center - Waupaca
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521334-00
Entity Address
800 Riverside Drive
Waupaca, WI 54981
Medicare Provider Number
521334
Participating Start Date
7/1/2013
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
SHOPKO PHARMACY #789
Pharmacy Address
825 W FULTON ST
WAUPACA, WI 54981
Pharmacy Comments
Contract Details
Approval Date
4/24/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig Kantos, CEO
(715) 258-1005
Contract Pharmacy Representative
Shopko
Tad Schilke, Director of Rx Merchandising & Marketing
(920) 429-7628
Signed By Date
4/24/2014
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