Covered Entity Details

DSH520136 Ascension SE Wisconsin Hospital, Inc. (Active) - information as of 4/25/2025 8:32:56 PM

Main Details

Name

Ascension SE Wisconsin Hospital, Inc.

Subdivision Name

ST. JOSEPH CAMPUS

Type

Disproportionate Share Hospital

Rural

340B ID

DSH520136

Medicare Provider Number

520136

Additional Details

Current Program Status

Active

Registration Date

8/31/2006

Participating Start Date

4/1/2004

Participating Approval Date

8/31/2006

Last Recertification Date

8/27/2024

Contacts

Authorizing Official

Ascension Elmbrook Memorial Hospital
Kurt Ronald Schley, President
(262) 785-2239

Primary Contact

Ascension WI
Cescilly Smith-Jenkins, 340B Program Director – Wisconsin
(414) 522-7533

Addresses

Street Address

5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
7/22/09 UPDATED ENTITY NAME, SUBDIVISION NAME (WAS WHEATON FRANCISCAN HEALTHCARE-ST. JOSEPH); 8/31/06 - NAME CHANGE (FORMERLY ST. JOSEPHS REGIONAL MEDICAL CENTER), UPDATED MEDICAID # (WAS 33270900)	08/31/2006

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
WI		1427007384

Shipping Addresses

Shipping Address 1

WHEATON FRANCISCAN, INC.
5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210

Shipping Address 2

Safecor Health, LLC
4060 Business Park Drive
Suite B
Columbus, OH 43204

Shipping Address 3

Ascension Rx
7701 Metropolis Drive
200C
Austin, TX 78744

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Termination Date	Last Updated On
Contract Detail	ACARIAHEALTH PHARMACY #11, INC	1311 W SAM HOUSTON PKWY N STE 130		HOUSTON	TX	77043-4015	04/11/2018	07/01/2018	08/04/2019	08/15/2019
Contract Detail	ACCREDO HEALTH GROUP INC	1620 CENTURY CENTER PKWY	# 109	MEMPHIS	TN	38134-8849	01/15/2016	04/01/2016		10/25/2016
Contract Detail	ACCREDO HEALTH GROUP INC	201 GREAT CIRCLE ROAD		NASHVILLE	TN	37228	01/15/2016	04/01/2016	01/01/2018	04/18/2018
Contract Detail	ACCREDO HEALTH GROUP INC	3000 ERICSSON DRIVE, SUITE 100		WARRENDALE	PA	15086-7502	01/15/2016	04/01/2016		10/25/2016
Contract Detail	ACCREDO HEALTH GROUP INC	2040 W RIO SALADO PKWY STE 101B		TEMPE	AZ	85281-2010	04/04/2017	07/01/2017		04/04/2017
Contract Detail	ACCREDO HEALTH GROUP, INC.	2825 W PERIMETER RD STE 112		INDIANAPOLIS	IN	46241	01/15/2016	04/01/2016	08/01/2023	01/10/2024
Contract Detail	ACCREDO HEALTH GROUP, INC.	6272 LEE VISTA BLVD STE 100		ORLANDO	FL	32822	01/15/2016	04/01/2016		10/25/2016
Contract Detail	ACCREDO HEALTH GROUP, INC.		PHARMACY 2 BOULDEN CIRCLE SUITE 1	NEW CASTLE	DE	19720	01/15/2016	04/01/2016		10/25/2016
Contract Detail	ACCREDO HEALTH GROUP, INC.	4750 E 450 S	SUITE A	WHITESTOWN	IN	46075	01/11/2022	04/01/2022		04/01/2022
Contract Detail	ADVANCED CARE SCRIPTS, INC	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	6251 CHANCELLOR DRIVE SUITE 101	ORLANDO	FL	32809	01/10/2024	04/01/2024		04/01/2024
Contract Detail	AFFILIATED HEALTH SERVICES, INC.	DBA ASCENSION RX 1303	30055 NORTHWESTERN HWY STE 225	FARMINGTON HILLS	MI	48334	04/13/2020	07/01/2020	03/09/2022	04/14/2022
Contract Detail	ALTSCRIPTS SPECIALTY PHARMACY	1636 MILLER PARK WAY		WEST MILWAUKEE	WI	53214-3604	04/15/2016	07/01/2016	04/01/2024	04/01/2024
Contract Detail	ASCENSION PHARMACY SERVICES, LLC	DBA ASCENSION RX 1303	30055 NORTHWESTERN HWY STE 225	FARMINGTON HILLS	MI	48334	01/13/2022	01/26/2022		01/27/2022
Contract Detail	ASCENSION RX 1001	ASCENSION PHARMACY SERVICES, LLC.	7701 METROPOLIS DR STE 200B	AUSTIN	TX	78744-3125	07/16/2021	10/01/2021		10/01/2021
Contract Detail	ASCENSION RX 1103	DBA ASCENSION RX 1114	10180 WASHINGTON AVE STE 102	MOUNT PLEASANT	WI	53177	01/13/2021	04/01/2021	05/06/2022	10/14/2022
Contract Detail	ASCENSION RX 3001	7701 METROPOLIS DR STE 200C		AUSTIN	TX	78744-3125	07/16/2021	10/01/2021	04/01/2022	10/14/2022
Contract Detail	ASCENSION WISCONSIN PHARMACY INC	DBA/ ASCENSION RX 1116	7400 W RAWSON AVE STE 140	FRANKLIN	WI	53132-8281	07/08/2020	10/01/2020		10/01/2020
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC	DBA ASCENSION RX 1115 (1112)	9252 N GREEN BAY RD	BROWN DEER	WI	53209-1104	01/13/2021	04/01/2021	05/06/2022	10/14/2022
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC.	DBA/ ASCENSION RX 1103	5000 W CHAMBERS ST RM 1801 ROOM 1801	MILWAUKEE	WI	53210-1650	06/17/2008	06/17/2008		10/25/2016
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC.	DBA/ ASCENSION RX 1104	19333 W NORTH AVE STE 390	BROOKFIELD	WI	53045-4132	10/14/2013	01/01/2014		10/25/2016
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC.	DBA/ ASCENSION RX 1106	201 N MAYFAIR RD	WAUWATOSA	WI	53226-4216	10/05/2015	01/01/2016		10/25/2016
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC.	DBA/ ASCENSION RX 1105	10101 S 27TH ST RM 1005	FRANKLIN	WI	53132-7209	10/09/2018	01/01/2019		01/01/2019
Contract Detail	ASCENSION WISCONSIN PHARMACY, INC.	DBA/ ASCENSION RX 1107	3237 S 16TH ST RM 121	MILWAUKEE	WI	53215-4526	07/12/2023	10/01/2023	11/28/2023	01/10/2024
Contract Detail	AVELLA OF DEER VALLEY, INC. #38	DBA AVELLA SPECIALTY PHARMACY	24416 N. 19TH AVE	PHOENIX	AZ	85085	04/18/2018	07/01/2018	10/01/2019	10/01/2019
Contract Detail	BIOPLUS SPECIALTY PHARMACY SERVICES, LLC	376 NORTHLAKE BLVD		ALTAMONTE SPRINGS	FL	32701-5261	01/17/2020	04/01/2020	10/31/2024	10/31/2024
Contract Detail	CAREMARK FLORIDA SPECIALTY PHARMACY LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7930 WOODLAND CENTER BLVD STE 500	TAMPA	FL	33614	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK ILLINOIS SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	800 BIERMANN CT STE B	MOUNT PROSPECT	IL	60056	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK KANSAS SPECIALTY PHARMACY	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	11162 RENNER BLVD	LENEXA	KS	66219	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK MASSACHUSETTS SPECIALTY PHARMAC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	25 BIRCH STREET, BLDG B, SUITE 100	MILFORD	MA	01757	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK MICHIGAN SPECIALTY PHARMACY, LL	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1307 ALLEN DR STE H	TROY	MI	48083	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK NEW JERSEY SPECIALTY PHCY, LLC	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	180 PASSAIC AVE UNIT B-5	FAIRFIELD	NJ	07004	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK NORTH CAROLINA SPECIALTY PHARMA	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	10700 WORLD TRADE BLVD STE 110	RALEIGH	NC	27617	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK TENNESSEE SPECIALTY PHARMACY, L	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	8370 WOLF LAKE DR STE 107	BARTLETT	TN	38133	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	1127 BRYN MAWR AVE SUITE A	REDLANDS	CA	92374	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CAREMARK, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	7251 S. EASTERN AVE.	LAS VEGAS	NV	89119	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CVS CAREMARK	DBA CVS/CAREMARK OR CF# 11506	1 GREAT VALLEY BOULEVARD	WILKES BARRE	PA	18706	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CVS CAREMARK ADVANCED TECHNOLOGY PHARMAC	DBA CVS/CAREMARK 48067	1780 WALL ST	MT PROSPECT	IL	60056	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CVS/SPECIALTY OR CARELONRX SPECIALTY PHA	CAREMARK, LLC	1001 SPINKS ROAD, STE 280	FLOWER MOUND	TX	75028	10/15/2020	01/01/2021		01/01/2021
Contract Detail	CYSTIC FIBROSIS SERVICES, LLC	DBA WALGREENS SPECIALTY PHARMACY #16280	10530 JOHN W ELLIOTT DR STE 200	FRISCO	TX	75033	07/13/2021	10/01/2021		10/01/2021
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	4100 S SAGINAW ST	STE D	FLINT	MI	48507-2683	04/08/2016	07/01/2016	05/04/2022	05/19/2022
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	G3320 BEECHER RD		FLINT	MI	48532-3614	04/08/2016	07/01/2016	12/31/2019	12/31/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY	1370 BUSCH PKWY		BUFFALO GROVE	IL	60089-4505	04/08/2016	07/01/2016	05/18/2018	07/15/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF FT LAUDER	DIPLOMAT SPECIALTY PHARMACY	15471 SW 12TH ST STE 207	SUNRISE	FL	33326	04/08/2016	07/01/2016	05/18/2018	07/15/2019
Contract Detail	DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN	DIPLOMAT SPECIALTY PHARMACY	1809 EXCISE AVENUE SUITE 204-208	ONTARIO	CA	91761	04/08/2016	07/01/2016	05/18/2018	07/15/2019
Contract Detail	ESI MAIL PHARMACY SERVICE	DBA EXPRESS SCRIPTS	7909 S HARDY DR STE 106	TEMPE	AZ	85284-1112	07/16/2021	10/01/2021		10/01/2021
Contract Detail	EXPRESS SCRIPTS	ESI MAIL PHARMACY SERVICE INC	4600 N HANLEY RD	SAINT LOUIS	MO	63134	07/16/2021	10/01/2021		10/01/2021
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	2040 ROUTE 130 NORTH	BURLINGTON	NJ	08016	07/16/2021	10/01/2021		10/01/2021
Contract Detail	EXPRESS SCRIPTS PHARMACY, INC.	DBA EXPRESS SCRIPTS	4750 E. 450 S.	WHITESTOWN	IN	46075	07/16/2021	10/01/2021		10/01/2021
Contract Detail	GENOA HEALTHCARE LLC	N171 W21840 CAYMUS CT		JACKSON	WI	53037	01/10/2024	04/01/2024		04/01/2024
Contract Detail	GENOA HEALTHCARE LLC	10424 WEST BLUEMOUND ROAD	SUITE B	MILWAUKEE	WI	53226	01/10/2024	04/01/2024		04/01/2024
Contract Detail	GENOA HEALTHCARE LLC	1717 TAYLOR AVE, STE P1		RACINE	WI	53403	01/10/2024	04/01/2024		04/01/2024
Contract Detail	GENOA HEALTHCARE LLC	333 E WASHINGTON STREET	STE 2100 ROOM 2107	WEST BEND	WI	53095	01/10/2024	04/01/2024		04/01/2024
Contract Detail	METRO MARKET PHARMACY #6301	17630 W BLUEMOUND RD		BROOKFIELD	WI	53045	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	METRO MARKET PHARMACY #6887	4279 S 76TH ST		GREENFIELD	WI	53220	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	METRO MARKET PHARMACY #853	12735 W CAPITOL DR		BROOKFIELD	WI	53005	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	METRO MARKET PHARMACY #885	6950 W. STATE STREET		WAUWATOSA	WI	53213	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	ONCOMED PHARMACEUTICAL SERVICES OF MA, L	D/B/A ONCO360	335 BEAR HILL RD STE 2100	WALTHAM	MA	02451	01/12/2018	04/01/2018	10/13/2019	10/13/2019
Contract Detail	ONCOMED THE ONCOLOGY PHARMACY OF BUFFALO	D/B/A ONCO360	140 JOHN JAMES AUDUBON PKWY STE 101	AMHERST	NY	14228	01/12/2018	04/01/2018	10/13/2019	10/13/2019
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	07/08/2020	10/01/2020	10/01/2020	04/13/2021
Contract Detail	OPTUM FRONTIER THERAPIES II, LLC	6425 SANTA MARGARITA ST UNIT 110		LAS VEGAS	NV	89118-1913	09/14/2023	10/01/2023		10/01/2023
Contract Detail	OPTUM FRONTIER THERAPIES, LLC	325 W ATHERTON RD	SUITE 1	FLINT	MI	48507-2601	09/14/2023	10/01/2023		10/01/2023
Contract Detail	OPTUM INFUSION SERVICES 305, LLC	15529 COLLEGE BLVD.		LENEXA	KS	66219-1351	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM PHARMACY 700, LLC	19 CHAPIN RD BLDG D, STE D8		PINE BROOK	NJ	07058	07/13/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 700, LLC	5700 DOT COM CT, STE 1000		OVIEDO	FL	32765	07/13/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	8131 W BOSTIAN RD STE A350		WOODINVILLE	WA	98072-5029	07/13/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 701, LLC	4100 S SAGINAW ST STE D		FLINT	MI	48507	04/29/2022	05/03/2022		05/04/2022
Contract Detail	OPTUM PHARMACY 701, LLC	1830 S HORNE		MESA	AZ	85204	01/10/2024	04/01/2024		04/01/2024
Contract Detail	OPTUM PHARMACY 701, LLC	4015 SHOPTON RD STE 600		CHARLOTTE	NC	28217-3025	01/10/2024	04/01/2024		04/01/2024
Contract Detail	OPTUM PHARMACY 702, LLC	1050 PATROL RD		JEFFERSONVILLE	IN	47130	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	3539 BLUECUTT RD		COLUMBUS	MS	39705	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	1100 LEE BRANCH LN		BIRMINGHAM	AL	35242-7298	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUM PHARMACY 705, LLC	1893 GENERAL GEORGE PATTON DR	STE 106	FRANKLIN	TN	37067-2655	07/13/2021	10/01/2021		10/01/2021
Contract Detail	OPTUM PHARMACY 801, INC.	24416 N 19TH AVE	STE. 100	PHOENIX	AZ	85085	07/08/2020	10/01/2020		10/01/2020
Contract Detail	OPTUMRX	2858 LOKER AVE E STE 100		CARLSBAD	CA	92010-6608	07/08/2020	10/01/2020	05/27/2022	09/14/2023
Contract Detail	OPTUMRX	OPTUMRX INC	6800 W 115TH ST STE 600	OVERLAND PARK	KS	66211-9838	07/08/2020	10/01/2020		10/01/2020
Contract Detail	PICK 'N SAVE PHARMACY #6360	7201 S. 76TH STREET		FRANKLIN	WI	53132	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK 'N SAVE PHARMACY #6857	4698 SOUTH WHITNALL AVENUE		ST. FRANCIS	WI	53235	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK 'N SAVE PHARMACY 6366	MEGA MARTS, LLC	5800 S. 108TH STREET	HALES CORNERS	WI	53130	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK 'N SAVE PHARMACY 6397	15170 W. GREENFIELD AVENUE		BROOKFIELD	WI	53005	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK 'N SAVE PHARMACY 6879	MEGA MARTS, LLC	2355 N. 35TH STREET	MILWAUKEE	WI	53210	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK 'N SAVE PHARMACY 6880	MEGA MARTS, LLC	1735 W. SILVER SPRING DRIVE	GLENDALE	WI	53209	10/14/2019	01/01/2020	12/05/2022	01/12/2023
Contract Detail	PICK N SAVE PHARMACY #6348	6462 S 27TH ST		OAK CREEK	WI	53154	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6368	17295 W CAPITOL DRIVE		BROOKFIELD	WI	53045	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6387	2320 W. RYAN ROAD		OAK CREEK	WI	53154	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6418	7401 W GOOD HOPE RD		MILWAUKEE	WI	53223	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6845	3701 S 27TH STREET		MILWAUKEE	WI	53221	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6846	2625 S 108TH ST		WEST ALLIS	WI	53227	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6862	8770 S HOWELL AVE		OAK CREEK	WI	53154	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PICK N SAVE PHARMACY #6878	250 W HOLT AVE		MILWAUKEE	WI	53207	10/14/2019	01/01/2020	03/04/2022	04/14/2022
Contract Detail	PRIME THERAPEUTICS SPECIALTY PHARMACY LL	ALLIANCERX WALGREENS PRIME #16568	2354 COMMERCE PARK DRIVE SUITE 100	ORLANDO	FL	32819-9992	07/13/2021	10/01/2021	10/01/2022	10/21/2022
Contract Detail	PROCARE PHARMACY DIRECT, L.L.C.	DBA CVS/SPECIALTY OR CARELONRX SPECIALTY	105 MALL BOULEVARD	MONROEVILLE	PA	15146	10/15/2020	01/01/2021		01/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA CVS/PHARMACY #2923	3250 HARDEN ST. EXT. SUITE #300	COLUMBIA	SC	29203	10/15/2020	01/01/2021		01/01/2021
Contract Detail	PROCARE PHARMACY, L.L.C.	DBA: CVS/PHARMACY #2909	1521 4TH AVE., SOUTH	BIRMINGHAM	AL	35233	10/15/2020	01/01/2021		01/01/2021
Contract Detail	RIVER MEDICAL PHARMACY LLC	4752 RESEARCH DR		SAN ANTONIO	TX	78240-5002	01/17/2020	04/01/2020	10/31/2024	10/31/2024
Contract Detail	SINA DRUG LLC	DBA ONCO360	1985 MARCUS AVE STE 120	NEW HYDE PARK	NY	11042	01/12/2018	04/01/2018	10/13/2019	10/13/2019
Contract Detail	SINA DRUG LLC	D/B/A ONCO 360	13410 EASTPOINT CENTRE DR STE 101	LOUISVILLE	KY	40223	01/12/2018	04/01/2018	10/13/2019	10/13/2019
Contract Detail	SORKIN'S RX LTD	D/B/A CAREMED PHARMACEUTICAL SERVICES	1985 MARCUS AVE STE 130	NEW HYDE PARK	NY	11042-2024	01/12/2018	04/01/2018	10/13/2019	10/13/2019
Contract Detail	SPECIALTY THERAPEUTIC CARE	1311 W SAM HOUSTON PKWY N STE 150		HOUSTON	TX	77043-4015	04/11/2018	07/01/2018	08/04/2019	08/15/2019
Contract Detail	WAL-MART CENTRAL FILL 10-2670	608 SPRING HILL DR # 3 SUITE 300		SPRING	TX	77386	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-1394	10600 W LAYTON AVE		GREENFIELD	WI	53228	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-1394	10600 W LAYTON AVE		GREENFIELD	WI	53228	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-1551	6701 S 27TH STREET		FRANKLIN	WI	53132	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-1551	6701 S 27TH STREET		FRANKLIN	WI	53132	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-2452	401 E. CAPITOL DRIVE		MILWAUKEE	WI	53212	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-2828	3355 S. 27TH STREET		MILWAUKEE (S)	WI	53215	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-2936	10330 W SILVER SPRINGS DR		MILWAUKEE	WI	53225	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-2936	10330 W SILVER SPRINGS DR		MILWAUKEE	WI	53225	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-3322	411 PEWAUKEE ROAD		PEWAUKEE	WI	53072	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-3322	411 PEWAUKEE ROAD		PEWAUKEE	WI	53072	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-4677	W159 S6530 MOORLAND ROAD		MUSKEGO	WI	53150	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-5315	2354 COMMERCE PARK DR.		ORLANDO	FL	32819	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-5438	15205 W GREENFIELD AVE		NEW BERLIN	WI	53151	09/05/2012	09/05/2012	08/01/2015	10/25/2016
Contract Detail	WAL-MART PHARMACY 10-5438	15205 W GREENFIELD AVE		NEW BERLIN	WI	53151	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-5438	15205 W GREENFIELD AVE		NEW BERLIN	WI	53151	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-5667	222 N CHICAGO AVE		SOUTH MILWAUKEE	WI	53172	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-5668	5301 S. 76TH STREET		GREENDALE	WI	53129	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WAL-MART PHARMACY 10-5997	9600 PARKSOUTH CT. SUITE 100		ORLANDO	FL	32837	07/13/2018	10/01/2018	08/29/2019	08/29/2019
Contract Detail	WALGREEN CO	DBA: WALGREENS #10963	6101 W GREENFIELD AVE	WEST ALLIS	WI	53214	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	Walgreen CO	DBA Walgreens Central Fill #21417	599 S Schmidt Rd Ste A	Bolingbrook	IL	60440-9405	01/12/2023	04/01/2023		04/01/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04672	2205 N CALHOUN RD	BROOKFIELD	WI	53005	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05002	N83W15701 APPLETON AVE	MENOMONEE FALLS	WI	53051	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04887	9449 S HOWELL AVE	OAK CREEK	WI	53154	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 01685	1400 EAST BRADY	MILWAUKEE	WI	53202	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07809	2625 W NATIONAL AVE	MILWAUKEE	WI	53204-1068	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04720	2222 W. CAPITOL	MILWAUKEE	WI	53206	10/31/2012	10/31/2012	01/15/2024	01/15/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00649	3701 S HOWELL AVE	MILWAUKEE	WI	53207	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02296	2727 W NORTH AVE	MILWAUKEE	WI	53208	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03813	3522 W WISCONSIN	MILWAUKEE	WI	53208	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 00295	4808 N HOPKINS	MILWAUKEE	WI	53209	10/31/2012	10/31/2012	11/08/2022	12/08/2022
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03109	7171 N. TEUTONIA AVENUE	MILWAUKEE	WI	53209	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #21396	320 E CAPITOL DR	MILWAUKEE	WI	53212	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12783	2826 N. MARTIN LUTHER KING DR.	MILWAUKEE	WI	53212-2314	10/31/2012	10/31/2012	12/05/2024	01/06/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04253	2656 N WAUWATOSA AVE	WAUWATOSA	WI	53213	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 10196	6600 WEST STATE STREET	WAUWATOSA	WI	53213	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04774	8333 W GREENFIELD AVE	WEST ALLIS	WI	53214	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04350	3233 SOUTH 27TH ST	MILWAUKEE	WI	53215	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02925	5115 WEST CAPITOL DR	MILWAUKEE	WI	53216	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03125	8615 N PORT WASHINGTON	FOX POINT	WI	53217	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 09549	5400 N PORT WASHINGTON RD	GLENDALE	WI	53217	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04984	6707 W. HAMPTON AVE.	MILWAUKEE	WI	53218	10/31/2012	10/31/2012	10/26/2023	10/31/2023
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06020	6030 W OKLAHOMA AVE	MILWAUKEE	WI	53219	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 06058	4296 S 76TH STREET	GREENFIELD	WI	53220	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04095	10800 W. CAPITOL	WAUWATOSA	WI	53222	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04537	7600 W CAPITOL DRIVE	MILWAUKEE	WI	53222	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS #12524	6020 W. BROWN DEER RD.	BROWN DEER	WI	53223	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07370	6442 N 76TH STREET	MILWAUKEE	WI	53223-6102	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03616	8488 W. BROWN DEER RD	MILWAUKEE	WI	53224	10/31/2012	10/31/2012	08/17/2015	10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04471	9040 W GOOD HOPE RD	MILWAUKEE	WI	53224	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 04254	5201 N. 91ST STREET	MILWAUKEE	WI	53225	10/31/2012	10/31/2012	12/03/2024	01/06/2025
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03578	2275 NORTH MAYFAIR ROAD	WAUWATOSA	WI	53226	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03394	9100 W BELOIT RD	MILWAUKEE	WI	53227	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 03882	2677 S 108TH ST	WEST ALLIS	WI	53227	10/31/2012	10/31/2012	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07568	5860 S 108TH STREET	HALES CORNERS	WI	53130	10/31/2012	10/31/2012		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 02752	15350 WEST BLUEMOUND RD	ELM GROVE	WI	53122	04/05/2013	07/01/2013		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05231	10725 W GREENFIELD AVE	WEST ALLIS	WI	53214	04/05/2013	07/01/2013	09/12/2019	10/07/2019
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07143	N56W15501 SILVER SPRING DR	MENOMONEE FALLS	WI	53051-5971	04/05/2013	07/01/2013		10/25/2016
Contract Detail	WALGREEN CO.	W002:DBA WALGREENS #07797	15640 W CAPITOL DR	BROOKFIELD	WI	53005-2221	04/05/2013	07/01/2013		10/25/2016
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #15322	826 N PLANKINTON AVE STE 100	MILWAUKEE	WI	53203	04/12/2013	07/01/2013		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05309	1441 CAPITOL DRIVE	PEWAUKEE	WI	53072	04/04/2014	07/01/2014	04/01/2024	04/04/2024
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07259	3855 SOUTH MOORLAND	NEW BERLIN	WI	53151-5225	04/04/2014	07/01/2014		10/25/2016
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 07731	N65W25055 MAIN STREET	SUSSEX	WI	53089	04/04/2014	07/01/2014		10/25/2016
Contract Detail	WALGREEN CO.	WALGREENS SPECIALTY PHARMACY #21254	2265 N MAYFAIR RD.	WAUWATOSA	WI	53226	01/10/2020	04/01/2020		04/01/2020
Contract Detail	WALGREEN CO.	DBA: WALGREENS # 05884	9527 S 27TH ST	FRANKLIN	WI	53132	01/12/2023	04/01/2023		04/01/2023
Contract Detail	WALGREENS MAIL SERVICE, INC.	8350 S RIVER PARKWAY		TEMPE	AZ	85284	04/09/2013	07/01/2013	07/02/2015	10/25/2016
Contract Detail	WALGREENS MAIL SERVICE, INC.		8337 S PARK CIRCLE	ORLANDO	FL	32819-9049	04/09/2013	07/01/2013	07/02/2015	10/25/2016
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15438	41460 HAGGERTY CIR S	CANTON	MI	48188	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #15443	10530 JOHN W ELLIOTT DR STE 100	FRISCO	TX	75033	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WALGREENS SPECIALTY PHARMACY, LLC	DBA WALGREENS SPECIALTY PHARMACY #16287	130 ENTERPRISE DR	PITTSBURGH	PA	15275	07/13/2021	10/01/2021		10/01/2021
Contract Detail	WFH-PE AND FW	DBA: WHEATON FRANCISCAN PHARMACY	13950 W. CAPITOL DR.	BROOKFIELD	WI	53005-2441	04/08/2014	07/01/2014	03/01/2016	10/25/2016
Contract Detail	WHEATON FRANCISCAN INFUSION PHARMACY	ST. JOSEPH REGIONAL MEDICAL CENTER	5000 W. CHAMBERS ST.	MILWAUKEE	WI	53210	04/08/2014	07/01/2014	05/15/2017	05/15/2017
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08772	5740 S PACKARD AVE	CUDAHY	WI	53110	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17277	2600 S 108TH ST	WEST ALLIS	WI	53227	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 03394	3860 S. 27TH ST.	MILWAUKEE	WI	53221	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 16654	4798 S MOORLAND RD	NEW BERLIN	WI	53151	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17043	8989 S HOWELL AVE	OAK CREEK	WI	53154	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 16059	2950 S CHASE AVE	MILWAUKEE	WI	53207	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08775	W63-N152 WASHINGTON AVE	CEDARBURG	WI	53012	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17570	1250 W SUNSET DR	WAUKESHA	WI	53189	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 16301	N95 W 17707 SHADY LN	MENOMONEE FALLS	WI	53051	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08764	2135 SILVERNAIL RD	PEWAUKEE	WI	53072	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17015	1501 MILLER PARK WAY	WEST MILWAUKEE	WI	53214	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08767	2607 N. DOWNER AVE.	MILWAUKEE	WI	53211	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08765	9220 W GREENFIELD	WEST ALLIS	WI	53214	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08771	7520 W BLUE MOUND RD	WAUWATOSA	WI	53213	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08768	240 E HAMPTON AVENUE	WHITEFISH BAY	WI	53217	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 05390	5220 WEST RAWSON AVE.	FRANKLIN	WI	53132	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	TARGET PHARMACY # 17584	3900 N 124TH ST	WAUWATOSA	WI	53222	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08763	1650 FARWELL	MILWAUKEE	WI	53202	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08769	5929 WEST LISBON AVE	MILWAUKEE	WI	53210	10/15/2020	01/01/2021	07/10/2023	09/22/2023
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 5676	7552 W. OKLAHOMA AVE.	WEST ALLIS	WI	53219	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17633	12725 W BLUEMOUND RD	BROOKFIELD	WI	53005	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 16567	1250 N PORT WASHINGTON RD	GRAFTON	WI	53024	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 16020	2401 KOSSOW RD	WAUKESHA	WI	53186	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 06855	17165 BLUEMOUND RD.	BROOKFIELD	WI	53005	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	CVS PHARMACY # 17451	7800 S LOVERS LANE RD	FRANKLIN	WI	53132	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08762	1316 W FOREST HOME AVE	MILWAUKEE	WI	53204	10/15/2020	01/01/2021	03/04/2021	01/10/2024
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08947	1130 W. SUNSET DR.	WAUKESHA	WI	53189	10/15/2020	01/01/2021		01/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 01267	7550 W. PERKINS PLACE	MILWAUKEE	WI	53216	04/15/2021	07/01/2021		07/01/2021
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA: CVS/PHARMACY # 08773	3030 W VILLARD AVE	MILWAUKEE	WI	53209	07/13/2021	10/01/2021	01/22/2025	03/04/2025
Contract Detail	WISCONSIN CVS PHARMACY, L.L.C.	DBA CVS/PHARMACY # 4996	N83W15550 APPLETON AVE	MENOMONEE FALLS	WI	53051-3714	07/13/2021	10/01/2021		10/01/2021

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH520136AA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Surgical 6th Floor	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook CARDIAC CATHETERIZATION	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Dialysis	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Outpatient / Elmbrook Pain Center	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Emergency Dept.	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Day Surgery	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook CARDIAC DIAGNOSTIC UNIT	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook RADIATION ONCOLOGY CTR	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook ULTRASOUND	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook RADIOLOGY	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook ANESTHESIA	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AM	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Women's Health Center	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AP	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Anesthesiology	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AQ	Child	DSH	WHEATON FRANCISCAN, INC.	RADIATION ONCOLOGY CTR	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Physical Rehab Acute Services	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Nuclear Medicine	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Respiratory Care Services	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AU	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook Radiology	19333 WEST NORTH AVENUE	Elmbrook	WI	Terminated
DSH520136AV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Surgery	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook MAMMOGRAPHY	19305 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136AX	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook EMAC PT CLINIC	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AY	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook PNAC	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136AZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook GI Lab	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136B	Child	DSH	WHEATON FRANCISCAN, INC.	WAUWATOSA CAMPUS	201 N MAYFAIR ROAD	WAUWATOSA	WI	Terminated
DSH520136BA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Laboratory	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136BB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook MRI	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook COMPUTERIZED TOMOGRAPHY	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BD	Child	DSH	WHEATON FRANCISCAN, INC.	Elmbrook-Ultrasound	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136BE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook PACU	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136BF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	St. Joseph Campus / Family and Internal Medicine	3070 N 51ST ST	MILWAUKEE	WI	Active
DSH520136BG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Brown Deer / Nuclear Medicine	9252 N. GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136BH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	BROWN DEER / CDU	9252 N. GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136BJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Urgent Care Unit	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	DAY SURGERY	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Respiratory / Pulmonary Diagnostics	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	ELECTROCARDIOLOGY / Cardiovascular Service	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BN	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Cardiac Pulmonary Rehabilitation	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BP	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	PHYSICAL THERAPY / Physical Rehab Acute	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BQ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	PHYSICAL THERAPY / Ambulatory Pain Mgmt	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	MRI / Ambulatory MRI	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	MRI / Ambulatory CT	201 N. MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BT	Child	DSH	WHEATON FRANCISCAN, INC.	Radiology-Diagnostic / Radiology Admin	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136BU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Ultrasound	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Nuclear Medicine	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Radiology-Diagnostic / Ambulatory Mammography	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BY	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	ANESTHESIOLOGY / Ambulatory Anesthesia	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136BZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	RECOVERY ROOM / Post Oper Recovery Room	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136C	Child	DSH	WHEATON FRANCISCAN, INC.	BROWN DEER CAMPUS	9252 N GREEN BAY ROAD	BROWN DEER	WI	Terminated
DSH520136CA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	OPERATING ROOM / Surgery Service	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136CB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WAUWATOSA OUTPATIENT CLINIC / WAUWATOSA GI	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136CC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / ICU	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wheaton Franciscan Performance Center	17000 W NORTH AVENUE	Brookfield	WI	Active
DSH520136CE	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / MRI-The Heart	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CF	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / PACU	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / WF Inc-Medical 5-South -Elmbrook	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CH	Child	DSH	WHEATON FRANCISCAN INC.	WFH - WISCONSIN HEART HOSPITAL - MI / ICU-The Heart	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WFH - ELMBROOK MEMORIAL INC / OB 4 North	19333 W NORTH AVE	BROOKFIELD	WI	Active
DSH520136CL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN, INC / Wound Healing	201 N MAYFAIR RD	WAUWATOSA	WI	Active
DSH520136CM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN, INC / WOMEN'S OP CENTER/ PNAC	201 N MAYFAIR RD	WAUWATOSA	WI	Terminated
DSH520136CP	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL / RECOVERY ROOM	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CQ	Child	DSH	WHEATON FRANCISCAN INC.	WISCONSIN HEART HOSPITAL - MI / MRI	10000W BLUEMOUND RD	WAUWATOSA	WI	Terminated
DSH520136CR	Child	DSH	WHEATON FRANCISCAN INC.	WFH - BROWN DEER / SJH PHYSIATRY	9252 N GREEN BAY RD	BROWN DEER	WI	Terminated
DSH520136CS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wheaton Franciscan / Behavorial Health	3070 N. 51st Street	Milwaukee	WI	Active
DSH520136CT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Interventional Radiology - Interventional Radiology	19333 W. North Ave.	Brookfield	WI	Active
DSH520136CU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Wauwatosa Vascular Catheterization - Vascular Catheterization	201 N. Mayfair Rd.	Wauwatosa	WI	Active
DSH520136CV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	St. Joseph Campus / Professional Office Building (POB) OB/GYN - OB/GYN	3070 N. 51st St.	Milwaukee	WI	Terminated
DSH520136CW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Cardiac Rehabilitation - Cardiac Rehabilitation	19333 West North Avenue	Brookfield	WI	Terminated
DSH520136CX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Observation - Elmbrook Acute Rehab - Rehabilitation	19333 West North Avenue	Brookfield	WI	Terminated
DSH520136CY	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Observation - Wauwatosa Pulmonary Rehab - Pulmonary Rehabilitation	201 N. Mayfair Rd.	Wauwatosa	WI	Terminated
DSH520136CZ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Vascular Lab - Vascular	10101 South 27th Street	Franklin	WI	Active
DSH520136D	Child	DSH	WHEATON FRANCISCAN, INC.	MIDWEST SPINE & ORTHOPEDIC HOSPITAL/WISCONSIN HEART HOSPITAL CAMPUS	10000 W BLUE MOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136DA	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Computerized Tomography - Computerized Tomography	10101 South 27th Street	Franklin	WI	Active
DSH520136DB	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Interventional Radiology - Radiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DC	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Nuclear Medicine - Nuclear Medicine	10101 South 27th Street	Franklin	WI	Active
DSH520136DD	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Mammography - Mammography	10101 South 27th Street	Franklin	WI	Active
DSH520136DE	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Cardiac Catheterization - Cardiac Catheterization	10101 South 27th Street	Franklin	WI	Active
DSH520136DF	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Respiratory Care Services - Respiratory Care	10101 South 27th Street	Franklin	WI	Active
DSH520136DG	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Rawson Radiology - Radiology	7400 West Rawson Avenue	Franklin	WI	Active
DSH520136DH	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Ultrasound - Ultrasound	10101 South 27th Street	Franklin	WI	Active
DSH520136DJ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Rehab Services - Rehabilitation	10101 South 27th Street	Franklin	WI	Terminated
DSH520136DK	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Day Surgery - Surgery	10101 South 27th Street	Franklin	WI	Active
DSH520136DL	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Cardiac Diagnostic Unit - Cardiac Diagnostics	10101 South 27th Street	Franklin	WI	Active
DSH520136DM	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Anesthesia - Anesthesiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DN	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Outpatient Services - Infusion Services	10101 South 27th Street	Franklin	WI	Active
DSH520136DP	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Emergency Department - Emergency	10101 South 27th Street	Franklin	WI	Active
DSH520136DQ	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Radiology - Radiology	10101 South 27th Street	Franklin	WI	Active
DSH520136DR	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin MRI - Magnetic Resonance Imaging	10101 South 27th Street	Franklin	WI	Active
DSH520136DS	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Surgery - Surgery	10101 South 27th Street	Franklin	WI	Active
DSH520136DT	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Center for Digestive Health - Gastroenterology	10101 South 27th Street	Franklin	WI	Active
DSH520136DU	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Vascular Venous Access - Vascular Access	10101 South 27th Street	Franklin	WI	Terminated
DSH520136DV	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Critical Care/ICU - Critical Care	10101 South 27th Street	Franklin	WI	Active
DSH520136DW	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin PACU - Recovery Room	10101 South 27th Street	Franklin	WI	Active
DSH520136DX	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Franklin Medical/Surgical Nursing - Medical/Surgical Nursing	10101 South 27th Street	Franklin	WI	Active
DSH520136E	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN CANCER CARE-ELMBROOK	19333 W.NORTH AVENUE	BROOKFIELD	WI	Active
DSH520136F	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	WHEATON FRANCISCAN CANCER CARE- WAUWATOSA	201 N. MAYFAIR ROAD	WAUWATOSA	WI	Active
DSH520136G	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook Rehab EMH Non-Nursing	19333 WEST NORTH AVENUE	Brookfield	WI	Active
DSH520136H	Child	DSH	Ascension SE Wisconsin Hospital, Inc.	Elmbrook-Diabetes Management	19333 WEST NORTH AVENUE	Brookfield	WI	Terminated
DSH520136J	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital POST OPERATIVE RECOV ROOMS	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136K	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Dialysis	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136L	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital REHAB SVC	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136M	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Emergency Dept	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136N	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Day Patients	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136Q	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Cardiac Catheterization	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136R	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Stress & Echo	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136S	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Respiratory Care Services	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136T	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital LAB	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136U	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital ULTRASOUND	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136V	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital NUCLEAR MEDICINE	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136W	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital RADIOLOGY	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated
DSH520136X	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital ICU & Telemetry	10000 West Bluemound Road	WAUWATOSA	WI	Terminated
DSH520136Y	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Surgery	10000 West Bluemound Road	WAUWATOSA	WI	Terminated
DSH520136Z	Child	DSH	WHEATON FRANCISCAN, INC.	Wisconsin Heart Hospital & Midwest Spine & Orthopedic Hospital Anesthesia	10000 WEST BLUEMOUND ROAD	WAUWATOSA	WI	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Insert	Change Request		Ascension Rx 7701 Metropolis Drive 200C Austin, TX 78744	9/13/2024 12:38 PM
Details	Last Recertification Date	Update	Recertification	8/23/2023 1:27:10 PM	8/27/2024 3:38:44 PM	8/27/2024 3:38 PM
Contacts	Authorizing Official	Update	Change Request	Freitag, Vanessa Vice President, Pharmacy Ascension 7158971183	Schley, Kurt Ronald President Ascension Elmbrook Memorial Hospital 2627852239	4/8/2024 7:06 AM
Contacts	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4144996174	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4145227533	11/28/2023 2:37 PM
Details	Last Recertification Date	Update	Recertification	9/13/2022 9:03:54 AM	8/23/2023 1:27:10 PM	8/23/2023 1:27 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	390816857001 (IL)		12/8/2022 9:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	0947747 (IA)		12/8/2022 9:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	169552500 (MN)		12/8/2022 9:38 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	11017100 (WI)		12/8/2022 9:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1427007384 (IL)		12/8/2022 9:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1427007384 (IA)		12/8/2022 9:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1427007384 (MI)		12/8/2022 9:38 AM
Medicaid Billing	NPI: Number	Delete	Change Request	1427007384 (MN)		12/8/2022 9:38 AM
Details	Last Recertification Date	Update	Recertification	9/10/2021 10:47:46 AM	9/13/2022 9:03:54 AM	9/13/2022 9:03 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 10:16:41 AM	9/10/2021 10:47:46 AM	9/10/2021 10:47 AM
Contacts	Authorizing Official	Update	Profile Change Request	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration Ascension 4144653711	Freitag, Vanessa Vice President, Pharmacy Ascension 7158971183	1/14/2021 3:35 PM
Contacts	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascension WI 4148746268	Smith-Jenkins, Cescilly 340B Program Director – Wisconsin Ascension WI 4144996174	10/15/2020 7:25 PM
Details	Last Recertification Date	Update	Recertification	9/9/2019 4:18:35 PM	9/10/2020 10:16:41 AM	9/10/2020 10:16 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/7/2020 4:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		0947747	8/7/2020 4:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IA	8/7/2020 4:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	8/7/2020 4:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		169552500	8/7/2020 4:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		MN	8/7/2020 4:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427007384	8/7/2020 4:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	8/7/2020 4:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427007384	8/7/2020 4:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		IA	8/7/2020 4:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427007384	8/7/2020 4:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		MI	8/7/2020 4:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1427007384	8/7/2020 4:55 PM
Medicaid Billing	NPI: State	Insert	Change Request		MN	8/7/2020 4:55 PM
Details	Last Recertification Date	Update	Recertification	8/22/2018 5:17:33 PM	9/9/2019 4:18:35 PM	9/9/2019 4:18 PM
Details	Entity Name	Update	Change Request	WHEATON FRANCISCAN, INC.	Ascension SE Wisconsin Hospital, Inc.	4/15/2019 10:15 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	1/2/2019 5:15 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		390816857001	1/2/2019 5:15 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		IL	1/2/2019 5:15 PM
Details	Last Recertification Date	Update	Recertification	11/29/2017 9:38:12 PM	8/22/2018 5:17:33 PM	8/22/2018 5:17 PM
Addresses	Shipping Address	Insert	Change Request		WHEATON FRANCISCAN, INC. 5000 WEST CHAMBERS STREET MILWAUKEE, WI 53210	7/3/2018 12:49 PM
Addresses	Shipping Address	Insert	Change Request		Safecor Health, LLC 4060 Business Park Drive Suite B Columbus, OH 43204	7/3/2018 12:49 PM
Details	Last Recertification Date	Update	Recertification	8/23/2016 12:00:00 AM	11/29/2017 9:38:12 PM	11/29/2017 9:38 PM
Contacts	Primary Contact	Update	Profile Change Request	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascesnion WI 4148746268	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascension WI 4148746268	10/10/2017 2:09 PM
Contacts	Authorizing Official	Update		Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration Ascension 4144653711	10/5/2017 2:03 PM
Contacts	Primary Contact	Update		Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy 4148746268	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy Ascesnion WI 4148746268	9/18/2017 5:55 PM
Contacts	Authorizing Official	Insert			Freitag, Vanessa Vice President, Ambulatory Services and Operational Integration 4144653711	8/13/2017 7:38 PM
Contacts	Primary Contact	Update		SANDERS, CHRIS DIRECTOR OF PHARMACY 4144473043	Smith-Jenkins, Cescilly Regional Director, 340B Pharmacy 4148746268	8/13/2017 7:38 PM
Addresses	Main Address	Insert			5000 WEST CHAMBERS STREET MILWAUKEE, WI 53210	5/18/2017 7:35 AM
Medicaid Billing	Medicaid: Is Primary	Update		True	False	8/23/2016 5:44 PM
Details	Last Recertification Date	Update		9/2/2015 12:00:00 AM	8/23/2016 12:00:00 AM	8/23/2016 5:44 PM
Details	Last Recertification Date	Update		9/5/2014 12:00:00 AM	9/2/2015 12:00:00 AM	9/2/2015 1:56 PM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	9/5/2014 12:00:00 AM	9/5/2014 12:17 PM
Details	Last Recertification Date	Update		7/1/2012 12:00:00 AM	9/12/2013 12:00:00 AM	9/12/2013 3:06 PM
Medicaid Billing	NPI: Number	Insert			1427007384	6/14/2012 6:55 AM
Details	Last Recertification Date	Update			7/1/2012 12:00:00 AM	6/14/2012 6:55 AM
Contacts	Primary Contact	Insert			SANDERS, CHRIS DIRECTOR OF PHARMACY 4144473043	12/15/2009 4:02 PM
Medicaid Billing	Medicaid: Is Primary	Insert			True	8/31/2006 9:30 AM
Medicaid Billing	Medicaid: Number	Insert			11017100	8/31/2006 9:30 AM
Medicaid Billing	Medicaid: State	Insert			WI	8/31/2006 9:30 AM
Details	Last Recertification Date	Insert				8/31/2006 9:30 AM
Details	Grant Number	Insert				8/31/2006 9:30 AM
Details	340B ID	Insert			DSH520136	8/31/2006 9:30 AM
Details	Is Authorizing Official EHB Data	Insert				8/31/2006 9:30 AM
Dates	Last Date That 340B Drugs Purchased	Insert				8/31/2006 9:30 AM
Details	Medicare Provider Number	Insert			520136	8/31/2006 9:30 AM
Details	Entity Name	Insert			WHEATON FRANCISCAN, INC.	8/31/2006 9:30 AM
Details	Program Code	Insert			DSH	8/31/2006 9:30 AM
Details	Entity Subname	Insert			ST. JOSEPH CAMPUS	8/31/2006 9:30 AM
Dates	Participating Approval Date	Insert			8/31/2006 12:00:00 AM	8/31/2006 9:30 AM
Details	State	Insert			Active	8/31/2006 9:30 AM
Dates	Registration Date	Insert			8/31/2006 12:00:00 AM	8/31/2006 9:30 AM
Dates	Signed By Date	Insert			8/29/2006 12:00:00 AM	8/31/2006 9:30 AM
Dates	Start Date	Insert			4/1/2004 12:00:00 AM	8/31/2006 9:30 AM
Terminations	Termination Comments	Insert				8/31/2006 9:30 AM
Terminations	Termination Date	Insert				8/31/2006 9:30 AM
Terminations	Termination Effective Date	Insert				8/31/2006 9:30 AM
Terminations	Termination Reason	Insert				8/31/2006 9:30 AM
Details	Comments Public	Insert			7/22/09 UPDATED ENTITY NAME, SUBDIVISION NAME (WAS WHEATON FRANCISCAN HEALTHCARE-ST. JOSEPH); 8/31/06 - NAME CHANGE (FORMERLY ST. JOSEPHS REGIONAL MEDICAL CENTER), UPDATED MEDICAID # (WAS 33270900)	8/31/2006 9:30 AM