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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
4/11/2019
Contract Begin Date
7/1/2019
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
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
4/11/2019
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