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BALSAM LAKE PHARMACY INC
CAH521337-06 ST. CROIX REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. CROIX REGIONAL MEDICAL CENTER
Subdivision Name
Frederic Clinic - RHC
Type
Critical Access Hospital
340B ID
CAH521337-06
Entity Address
205 Oak Street West
Frederic, WI 54837
Medicare Provider Number
521337
Outpatient Facility Provider Number
528555
Participating Start Date
4/1/2014
Last Recertification Date
9/10/2019
Entity Termination Date
10/1/2019
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
10/1/2019
Covered Entity Terminated
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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