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BALSAM LAKE PHARMACY INC
CAH521337-05 ST. CROIX REGIONAL MEDICAL CENTER
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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
BALSAM LAKE PHARMACY INC
Pharmacy Address
315 MAIN ST
BALSAM LAKE, WI 54810
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sally Bajak, CFO
(715) 483-0556
Contract Pharmacy Representative
Prohaska Pharmacy Group
Joshua J Prohaska, President
(715) 532-3339
Signed By Date
10/15/2018
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