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ASCENSION WISCONSIN PHARMACY, INC.
DSH520136 Ascension SE Wisconsin Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension SE Wisconsin Hospital, Inc.
Subdivision Name
ST. JOSEPH CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH520136
Entity Address
5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210
Medicare Provider Number
520136
Participating Start Date
4/1/2004
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
ASCENSION WISCONSIN PHARMACY, INC.
Pharmacy Address
DBA/ ASCENSION RX 1105
10101 S 27TH ST RM 1005
FRANKLIN, WI 53132-7209
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
Ascension
Kristopher Cyr, Manager Pharmacy Operations
(262) 687-2151
Signed By Date
10/9/2018
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