Contract Pharmacy Details

WAL-MART PHARMACY 10-5997
CAH521337-05 ST. CROIX REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

ST. CROIX REGIONAL MEDICAL CENTER

Subdivision Name

Unity Clinic

Type

Critical Access Hospital

340B ID

CAH521337-05

Entity Address

1504 190th Avenue
Balsam Lake, WI 54810

Medicare Provider Number

521337

Outpatient Facility Provider Number

528605

Participating Start Date

4/1/2013

Last Recertification Date

8/26/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-5997

Pharmacy Address

9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837

Pharmacy Comments

Contract Details

Approval Date

7/9/2018

Contract Begin Date

10/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/17/2023
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Sally Bajak, CFO
(715) 483-0556

Contract Pharmacy Representative

Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498

Signed By Date

7/9/2018

340B Drug Pricing Program Database