Contract Pharmacy Details

WALGREEN CO.
CAH521337-05 ST. CROIX REGIONAL MEDICAL CENTER

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

WALGREEN CO.

Pharmacy Address

WALGREENS SPECIALTY PHARMACY #21254
2265 N MAYFAIR RD.
WAUWATOSA, WI 53226

Pharmacy Comments

Contract Details

Approval Date

1/7/2020

Contract Begin Date

4/1/2020

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

1/7/2020

340B Drug Pricing Program Database