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WOOD RIVER PHARMACY
CAH521337-00 ST. CROIX REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. CROIX REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521337-00
Entity Address
235 STATE STREET
ST. CROIX FALLS, WI 54024
Medicare Provider Number
521337
Participating Start Date
1/1/2011
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WOOD RIVER PHARMACY
Pharmacy Address
BELLICOSE INTERNATIONAL INC
122 W MADISON AVE
GRANTSBURG, WI 54840-5484
Pharmacy Comments
Contract Details
Approval Date
12/12/2012
Contract Begin Date
12/12/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Tremble, CFO
(715) 483-0317
Contract Pharmacy Representative
Chris Witzany, R. PH.
(715) 463-2525
Signed By Date
9/28/2012
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