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LINDSTROM THRIFTY WHITE PHARMACY
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
LINDSTROM THRIFTY WHITE PHARMACY
Pharmacy Address
30699 LINCOLN RD
LINDSTROM, MN 55045-8083
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
1/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sally Bajak, CFO
(715) 483-0556
Contract Pharmacy Representative
Lindstrom Thrifty White Pharmacy
Matthew Garrison, PIC, Pharm D
(651) 257-4074
Signed By Date
1/7/2020
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