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WAL-MART PHARMACY 10-1396
SCH520109-00 MILE BLUFF MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
MILE BLUFF MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH520109-00
Entity Address
1050 DIVISION STREET
Mauston, WI 53948
Medicare Provider Number
520109
Participating Start Date
1/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1396
Pharmacy Address
920 HIGHWAY 12
BARABOO, WI 53913
Pharmacy Comments
Contract Details
Approval Date
10/17/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/7/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Francis J. Fish, CFO
(608) 847-2992
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/17/2016
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