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WALGREENS SPECIALTY PHARMACY, LLC
CAH521337-01 ST. CROIX REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. CROIX REGIONAL MEDICAL CENTER
Subdivision Name
FREDERIC CLINIC
Type
Critical Access Hospital
340B ID
CAH521337-01
Entity Address
205 Oak Street West
FREDERIC, WI 54837
Medicare Provider Number
521337
Outpatient Facility Provider Number
528555
Participating Start Date
1/1/2011
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
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
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