Contract Pharmacy Details

AVELLA OF ORLANDO
CAH521337-03 ST. CROIX REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

ST. CROIX REGIONAL MEDICAL CENTER

Subdivision Name

ST. CROIX FALLS CLINIC

Type

Critical Access Hospital

340B ID

CAH521337-03

Entity Address

216 South Adams Street
ST. CROIX FALLS, WI 54024

Medicare Provider Number

521337

Outpatient Facility Provider Number

528604

Participating Start Date

1/1/2011

Last Recertification Date

8/26/2024

Pharmacy Details

Pharmacy Name

AVELLA OF ORLANDO

Pharmacy Address

100 TECHNOLOGY PARK STE 155
LAKE MARY, FL 32746-6205

Pharmacy Comments

Contract Details

Approval Date

4/8/2015

Contract Begin Date

7/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2016
Pharmacy closed

Contacts

Covered Entity Signing Official

John Tremble, CFO
(715) 483-0317

Contract Pharmacy Representative

Avella
Nancy McCutcheon, Senior Vice President, Strategic Services
(651) 983-0677

Signed By Date

4/8/2015

340B Drug Pricing Program Database