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BALSAM LAKE PHARMACY INC
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
BALSAM LAKE PHARMACY INC
Pharmacy Address
315 MAIN ST
BALSAM LAKE, WI 54810
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
7/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Tremble, CFO
(715) 483-0317
Contract Pharmacy Representative
Joshua J. Prohaska, President
(715) 532-3339
Signed By Date
7/16/2015
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