Application Status Query

Instructions: 

Please allow one hour after receipt of your status update email for the updates to be reflected in the online checklist.

Please verify the checklist information below, including your address. If your address has changed, please e-mail your application number, name, profession, along with your old and new address. The Credentialing department posts status information following receipt and review of application materials.

As of  :  03/14/2016
Application#  :  564189
Name  :  MARSHFIELD CLINIC REGIONAL MEDICAL CENTER
Profession  :  Pharmacy (in state)
Address  :  MARSHFIELD, WI
Application Status  :  Withdrawn (Abandoned)


Requirements Not Met:
Description Status Comments (Please note, not all requirements will include comments)
Type of License Not Met
11/23/18: file marked “abandoned” due to lack of activity. If applicant would like to obtain Wisconsin licensure, applicant will need to submit Application Form 609, fees, and all requirements. /tg;
Federal Identification Number Collection Not Met
3/3/2016: Need to submit FEIN number on our form #2552 by mail, fax (608-261-7083) or email to: DSPSCredPharmacy@WI.gov. A copy of the form has been mailed to you. Or you can get a copy from our website – http://dsps.wi.gov. (Go to Licenses/Permits/Registrations > Health Professions > Pharmacy (In State) > Application Forms > Form #2552 Addendum to Application – Business Entities)
Self Inspection Report Not Met
3/14/16:RECEIVED #923, SELF INSPECTION COVER SHEET. STILL NEED SELF INSPECTION REPORT, #2550.

3/3/2016: please submit self inspection cover sheet (form #923). You are also required to complete the self-inspection report (Form #2550), get it notarized and submit to DSPS. The form is available for viewing and for download on our website: http://dsps.wi.gov/Default.aspx?Page=5a1314b6-10d4-4da6-a772-861360776e04.

Requirements Met:
Description Status Comments (Please note, not all requirements will include comments)
Application Fee Met
$75
Applicant address of facility Met
Mailing address until day of opening Met
Proposed Opening date Met
06-28-16
Owner Partners Corporate Officers, titles, etc Met
Pharmacy Hours Daily Saturday Sunday Met
Barrier Requested? Met
Managing Pharmacist Affidavit and License # Met
Inspection Ready Date (self inspection will be used) Met
6/28/16
Affidavit of applicant, signed. Met
Floor plan - original (scaled to size, location of sink and refrigerator with prescription counter space clearly indicated) Met
03/14/16:RECEIVED.

3/3/16:RECEIVED FLOOR PLAN. HOWEVER THE REFRIGERATOR AND SINK WAS NOT LISTED. PLEASE RESUBMIT CLEARLY SHOWING WHERE THE REFRIGERATOR AND SINK ARE LOCATED.
Submit Request to DEA (for your info only) Met