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FROEDTERT HEALTH ST. JOSEPH'S HOSPITAL P
PED523300-00 CHILDREN'S HOSPITAL OF WISCONSIN, INC.
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Covered Entity Details
Entity Name
CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Subdivision Name
Type
Children's Hospital
340B ID
PED523300-00
Entity Address
9000 W. WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
523300
Participating Start Date
4/1/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
FROEDTERT HEALTH ST. JOSEPH'S HOSPITAL P
Pharmacy Address
3200 PLEASANT VALLEY ROAD
SUITE 1A
WEST BEND, WI 53095
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2020
Ownership change
Contacts
Covered Entity Signing Official
Scott Turner, COO CHW and EVP CHHS
(414) 266-2648
Contract Pharmacy Representative
Children's Hospital of Wisconsin
Thomas Lausten, Director of Pharmacy Services
(414) 266-2234
Signed By Date
4/15/2019
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