Contract Pharmacy Details

NICOLET PHARMACY
CH051490 NORTHERN HEALTH CENTERS, INC.

Covered Entity Details

Entity Name

NORTHERN HEALTH CENTERS, INC.

Subdivision Name

DBA NORTHERN HEALTH CENTERS, INC.

Type

HRSA-Funded Health Center

340B ID

CH051490

Entity Address

15397 HWY 32
LAKEWOOD, WI 54138-0179

Grant Number

H80CS00491

Participating Start Date

1/1/1999

Last Recertification Date

2/12/2018

Entity Termination Date

4/1/2019

Pharmacy Details

Pharmacy Name

NICOLET PHARMACY

Pharmacy Address

15481 COMMERCIAL RD STE A
LAKEWOOD, WI 54138-9677

Pharmacy Comments

Contract Details

Approval Date

10/6/2004

Contract Begin Date

10/6/2004

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Contract Pharmacy Representative

Signed By Date

340B Drug Pricing Program Database