Contract Pharmacy Details

MENOMINEE TRIBAL CLINIC PHCY
FQHC638544 Menominee Indian Tribe of Wisconsin

Entity Name

Menominee Indian Tribe of Wisconsin

Subdivision Name

Menominee Tribal Clinic

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638544

Entity Address

W3275 WOLF RIVER ROAD
Keshena, WI 54135

Grant Number

Participating Start Date

1/1/2017

Last Recertification Date

2/5/2024

Pharmacy Name

MENOMINEE TRIBAL CLINIC PHCY

Pharmacy Address

IHS
W3275 WOLF RIVER DR
P.O. BOX 970
KESHENA, WI 54135-9202

Pharmacy Comments

Approval Date

12/15/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date

7/13/2022

Termination Reason

Agreement registered in error

Covered Entity Signing Official

Rosemary Simon Kazik, Insurance Director
(715) 799-5188

Signed By Date

12/15/2016

Contract Pharmacy Representative

Gary Lewandowski, Pharmact director
(715) 799-3368