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FROEDTERT HOME INFUSION
DSH520177 FROEDTERT MEMORIAL LUTHERAN HOSPITAL
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Covered Entity Details
Entity Name
FROEDTERT MEMORIAL LUTHERAN HOSPITAL
Subdivision Name
FORMERLY JOHN L. DOYNE HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH520177
Entity Address
9200 WEST WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
520177
Participating Start Date
7/1/1996
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
FROEDTERT HOME INFUSION
Pharmacy Address
N86W12999 NIGHTINGALE WAY STE 1047
MENOMONEE FALLS, WI 53051-2102
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925
Contract Pharmacy Representative
Froedtert Health Pharmacy, LLC
Dale Drizd, Director of Retail and Pharmacy Services
(262) 532-5168
Signed By Date
10/14/2019
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