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BLAIR PHARMACY THE
CAH521316-00 Tri-County Memorial Hospital, Inc.
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Covered Entity Details
Entity Name
Tri-County Memorial Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521316-00
Entity Address
18601 Lincoln Street
Whitehall, WI 54773
Medicare Provider Number
521316
Participating Start Date
7/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
BLAIR PHARMACY THE
Pharmacy Address
125 W BROADWAY ST
BLAIR, WI 54616-9367
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/20/2024
Pharmacy closed
Contacts
Covered Entity Signing Official
Roxane Schleich, CFO, Regional
(715) 538-4361
Contract Pharmacy Representative
The Blair Pharmacy
Daniel B Molstad, Pharmacist
(608) 989-2919
Signed By Date
1/15/2018
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