Contract Pharmacy Details

WALGREEN CO.
CAH521337-03 ST. CROIX REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

ST. CROIX REGIONAL MEDICAL CENTER

Subdivision Name

ST. CROIX FALLS CLINIC

Type

Critical Access Hospital

340B ID

CAH521337-03

Entity Address

216 South Adams Street
ST. CROIX FALLS, WI 54024

Medicare Provider Number

521337

Outpatient Facility Provider Number

528604

Participating Start Date

1/1/2011

Last Recertification Date

8/26/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #11860
502 S. MAIN ST.
RICE LAKE, WI 54868-2576

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

8/23/2024
Business decision by covered entity and/or pharmacy

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

340B Drug Pricing Program Database