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WALGREEN CO.
CAH521317-00 Ascension Calumet Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension Calumet Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521317-00
Entity Address
614 MEMORIAL DRIVE
CHILTON, WI 53014
Medicare Provider Number
521317
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #13065
245 W. CALUMET ST.
CHILTON, WI 53014
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer Derks, Chief Administrative Officer
(920) 849-1806
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/14/2020
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