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PHILLIPS ROCHE-A-CRI PHARMACY
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
PHILLIPS ROCHE-A-CRI PHARMACY
Pharmacy Address
402 W LAKE ST
PO BOX 170
FRIENDSHIP, WI 53934
Pharmacy Comments
Contract Details
Approval Date
1/23/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/6/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Francis J. Fish, CFO
(608) 847-2992
Contract Pharmacy Representative
MBMC Phillips Pharmacy
Wayne MaCardy, Managing Pharmacist
(608) 847-5949
Signed By Date
1/23/2017
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