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BLACK RIVER FALLS CLIN PH
CAH521333-00 BLACK RIVER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BLACK RIVER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521333-00
Entity Address
711 WEST ADAMS STREET
BLACK RIVER FALLS, WI 54615
Medicare Provider Number
521333
Participating Start Date
1/1/2014
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
BLACK RIVER FALLS CLIN PH
Pharmacy Address
610 W ADAMS ST
BLACK RIVER FALLS, WI 54615-9010
Pharmacy Comments
Contract Details
Approval Date
7/12/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/10/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carl Selvick, President and CEO
(715) 284-1301
Contract Pharmacy Representative
Black River Falls Clinic Pharmacy
Barbara Hagenbrock, Pharmacy Director/Owner
(715) 284-4089
Signed By Date
7/12/2023
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