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WOOD RIVER PHARMACY
CAH521331-00 BURNETT MEDICAL CENTER INC
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Covered Entity Details
Entity Name
BURNETT MEDICAL CENTER INC
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521331-00
Entity Address
257 W SAINT GEORGE STREET
GRANTSBURG, WI 54840
Medicare Provider Number
521331
Participating Start Date
1/1/2015
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WOOD RIVER PHARMACY
Pharmacy Address
BELLICOSE INTERNATIONAL INC
122 W MADISON AVE
GRANTSBURG, WI 54840-5484
Pharmacy Comments
Contract Details
Approval Date
7/2/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gordon D Forbort, CFO
(715) 463-7281
Contract Pharmacy Representative
Chris Witzany, R. PH.
(715) 463-2525
Signed By Date
7/2/2015
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