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WAL-MART PHARMACY 10-1305
CAH521319-00 EDGERTON HOSPITAL & HEALTH SERVICES
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Covered Entity Details
Entity Name
EDGERTON HOSPITAL & HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521319-00
Entity Address
11101 N SHERMAN ROAD
EDGERTON, WI 53534
Medicare Provider Number
521319
Participating Start Date
10/1/2015
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1305
Pharmacy Address
3800 DEERFIELD DR
JANESVILLE, WI 53545
Pharmacy Comments
Contract Details
Approval Date
10/9/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Charles Roeder, Vice President/CFO
(608) 884-1656
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/9/2015
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