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WAL-MART PHARMACY 10-5315
CAH521328-00 MARSHFIELD MEDICAL CENTER LADYSMITH
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Covered Entity Details
Entity Name
MARSHFIELD MEDICAL CENTER LADYSMITH
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521328-00
Entity Address
1200 Port Arthur Road
LADYSMITH, WI 54848
Medicare Provider Number
521328
Participating Start Date
10/1/2019
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/16/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David J Kuehn, Chief Financial Officer
(715) 532-5561 Ext: 1106
Contract Pharmacy Representative
Rusk County Memorial Hospital
Paul E Finn, Pharmacy Director
(715) 532-5561 Ext: 3122
Signed By Date
4/16/2018
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