| Addresses | Shipping Address | Insert | Change Request | | Ascension Rx
7701 Metropolis Drive
200C
Austin, TX 78744 | 10/3/2024 2:34 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2023 1:16:34 PM | 8/19/2024 4:47:36 PM | 8/19/2024 4:47 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Freitag, Vanessa
Vice President, Pharmacy
Ascension
7158971183 | Bergmann, Michael
President
Ascension Wisconsin
9208318913 | 4/2/2024 8:05 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 8:50:16 AM | 8/23/2023 1:16:34 PM | 8/23/2023 1:16 PM |
| Medicaid Billing | NPI: Number | Insert | Change Request | | 1376541748 | 12/7/2022 3:09 PM |
| Medicaid Billing | NPI: State | Insert | Change Request | | WI | 12/7/2022 3:09 PM |
| Details | Last Recertification Date | Update | Recertification | 9/9/2021 5:12:18 PM | 9/13/2022 8:50:16 AM | 9/13/2022 8:50 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2020 8:57:44 AM | 9/9/2021 5:12:18 PM | 9/9/2021 5:12 PM |
| Details | Entity Name | Update | Change Request | CALUMET MEDICAL CENTER, INC. | Ascension Calumet Hospital, Inc. | 6/22/2021 7:45 AM |
| Contacts | Authorizing Official | Update | Change Request | Derks, Jennifer
Chief Administrative Officer
Ascension Calumet Hospital
9208491806 | Freitag, Vanessa
Vice President, Pharmacy
Ascension
7158971183 | 4/13/2021 1:17 PM |
| Contacts | Primary Contact | Update | Change Request | Pearce, Bryan
340B Program Director - North Region
Ascension WI
7154790312 | Smith-Jenkins, Cescilly
340B Program Director – Wisconsin
Ascension WI
4144996174 | 4/9/2021 9:50 AM |
| Details | Last Recertification Date | Update | Recertification | 9/10/2019 1:36:00 PM | 9/10/2020 8:57:44 AM | 9/10/2020 8:57 AM |
| Addresses | Billing Address | Insert | Change Request | | St Eliz/Cal Med Ctr PHS
ATTN: Pharmacy Dept
1506 S Oneida St
Appleton, WI 54915 | 12/20/2019 10:33 AM |
| Addresses | Shipping Address | Insert | Change Request | | Calumet Medical Center
614 Memorial Drive
Chilton, WI 53014 | 12/20/2019 10:33 AM |
| Addresses | Shipping Address | Insert | Change Request | | St Eliz/Cal Med Ctr PHS
ATTN: Pharmacy Dept
1506 S Oneida St
Appleton, WI 54915 | 12/20/2019 10:33 AM |
| Details | Last Recertification Date | Update | Recertification | 8/16/2018 10:06:45 AM | 9/10/2019 1:36:00 PM | 9/10/2019 1:36 PM |
| Details | Last Recertification Date | Update | Recertification | 11/3/2017 11:56:35 AM | 8/16/2018 10:06:45 AM | 8/16/2018 10:06 AM |
| Contacts | Primary Contact | Update | Recertification | WEBER, JENNIFER
DIRECTOR OF PATIENT CARE SERVICES
9208492386-289 | Pearce, Bryan
340B Program Director - North Region
Ascension WI
7154790312 | 11/3/2017 11:56 AM |
| Details | Last Recertification Date | Update | Recertification | 8/25/2016 12:00:00 AM | 11/3/2017 11:56:35 AM | 11/3/2017 11:56 AM |
| Contacts | Authorizing Official | Update | | Derks, Jennifer
Chief Administrative Officer
9208491806 | Derks, Jennifer
Chief Administrative Officer
Ascension Calumet Hospital
9208491806 | 10/20/2017 6:57 AM |
| Contacts | Authorizing Official | Insert | | | Derks, Jennifer
Chief Administrative Officer
9208491806 | 3/1/2017 8:34 AM |
| Addresses | Main Address | Insert | | |
614 MEMORIAL DRIVE
CHILTON, WI 53014 | 3/1/2017 8:33 AM |
| Details | Last Recertification Date | Update | | 8/24/2015 12:00:00 AM | 8/25/2016 12:00:00 AM | 8/25/2016 9:30 AM |
| Details | Last Recertification Date | Update | | 8/6/2014 12:00:00 AM | 8/24/2015 12:00:00 AM | 8/24/2015 11:29 AM |
| Details | Last Recertification Date | Update | | 8/19/2013 12:00:00 AM | 8/6/2014 12:00:00 AM | 8/6/2014 8:52 AM |
| Contacts | Primary Contact | Insert | | | WEBER, JENNIFER
DIRECTOR OF PATIENT CARE SERVICES
9208492386-289 | 1/8/2014 12:30 PM |
| Details | Last Recertification Date | Update | | 8/19/2013 2:46:24 PM | 8/19/2013 12:00:00 AM | 1/8/2014 12:30 PM |
| Details | Last Recertification Date | Update | | 7/1/2012 12:00:00 AM | 8/19/2013 2:46:24 PM | 8/19/2013 2:46 PM |
| Details | Last Recertification Date | Update | | | 7/1/2012 12:00:00 AM | 6/1/2012 10:24 AM |
| Details | Comments Public | Insert | | | 4/11/12- deleted medicaid #(was 11015300) | 4/11/2012 2:33 PM |
| Details | Last Recertification Date | Insert | | | | 11/23/2010 1:47 PM |
| Details | Grant Number | Insert | | | | 11/23/2010 1:47 PM |
| Details | 340B ID | Insert | | | CAH521317-00 | 11/23/2010 1:47 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 11/23/2010 1:47 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 11/23/2010 1:47 PM |
| Details | Medicare Provider Number | Insert | | | 521317 | 11/23/2010 1:47 PM |
| Details | Entity Name | Insert | | | CALUMET MEDICAL CENTER, INC. | 11/23/2010 1:47 PM |
| Details | Program Code | Insert | | | CAH | 11/23/2010 1:47 PM |
| Details | Entity Subname | Insert | | | | 11/23/2010 1:47 PM |
| Dates | Participating Approval Date | Insert | | | 11/16/2010 12:00:00 AM | 11/23/2010 1:47 PM |
| Details | State | Insert | | | Active | 11/23/2010 1:47 PM |
| Dates | Registration Date | Insert | | | 11/16/2010 12:00:00 AM | 11/23/2010 1:47 PM |
| Dates | Signed By Date | Insert | | | 9/24/2010 12:00:00 AM | 11/23/2010 1:47 PM |
| Dates | Start Date | Insert | | | 1/1/2011 12:00:00 AM | 11/23/2010 1:47 PM |
| Terminations | Termination Comments | Insert | | | | 11/23/2010 1:47 PM |
| Terminations | Termination Date | Insert | | | | 11/23/2010 1:47 PM |
| Terminations | Termination Effective Date | Insert | | | | 11/23/2010 1:47 PM |
| Terminations | Termination Reason | Insert | | | | 11/23/2010 1:47 PM |