340B Drug Pricing Program Database
Home
Search
Search Covered Entities
Search Contract Pharmacies
Search Manufacturers
Reports
Help
Login
BALSAM LAKE PHARMACY INC
CAH521337-05 ST. CROIX REGIONAL MEDICAL CENTER
Print
Covered Entity Details
Entity Name
ST. CROIX REGIONAL MEDICAL CENTER
Subdivision Name
Unity Clinic
Type
Critical Access Hospital
340B ID
CAH521337-05
Entity Address
1504 190th Avenue
Balsam Lake, WI 54810
Medicare Provider Number
521337
Outpatient Facility Provider Number
528605
Participating Start Date
4/1/2013
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
Continue Your Session
For security reasons inactive sessions are automatically closed.
Your session will be closed shortly if you don't continue it.
Continue Your Session