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SIREN PHARMACY
CAH521337-06 ST. CROIX REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. CROIX REGIONAL MEDICAL CENTER
Subdivision Name
Frederic Clinic - RHC
Type
Critical Access Hospital
340B ID
CAH521337-06
Entity Address
205 Oak Street West
Frederic, WI 54837
Medicare Provider Number
521337
Outpatient Facility Provider Number
528555
Participating Start Date
4/1/2014
Last Recertification Date
9/10/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
SIREN PHARMACY
Pharmacy Address
24106 STATE RD 35
PO BOX 503
SIREN, WI 54872
Pharmacy Comments
Contract Details
Approval Date
10/3/2014
Contract Begin Date
1/1/2015
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
SIREN PHARMACY
John Peterson, Owner
(715) 349-2221
Signed By Date
10/3/2014
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