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SIREN PHARMACY
CAH521331-00 BURNETT MEDICAL CENTER INC
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Covered Entity Details
Entity Name
BURNETT MEDICAL CENTER INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521331-00
Entity Address
257 W SAINT GEORGE STREET
GRANTSBURG, WI 54840
Medicare Provider Number
521331
Participating Start Date
1/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
SIREN PHARMACY
Pharmacy Address
24106 STATE RD 35
PO BOX 503
SIREN, WI 54872
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gordon D Forbort, CFO
(715) 463-7281
Contract Pharmacy Representative
SIREN PHARMACY
John Peterson, Owner
(715) 349-2221
Signed By Date
10/15/2020
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