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WAL-MART PHARMACY 10-2421
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
WAL-MART PHARMACY 10-2421
Pharmacy Address
2212 GLACIER DRIVE
ST. CROIX FALLS, WI 54024
Pharmacy Comments
Contract Details
Approval Date
7/16/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/17/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Tremble, CFO
(715) 483-0317
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/16/2015
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