Contract Pharmacy Details

AFFILIATED HEALTH SERVICES, INC.
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Covered Entity Details

Entity Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520009

Entity Address

1506 S. Oneida St.
Appleton, WI 54915

Medicare Provider Number

520009

Participating Start Date

4/1/2012

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

AFFILIATED HEALTH SERVICES, INC.

Pharmacy Address

DBA ASCENSION RX 1303
30055 NORTHWESTERN HWY
STE 225
FARMINGTON HILLS, MI 48334

Pharmacy Comments

Contract Details

Approval Date

4/13/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

3/9/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Monica Ann Hilt, President
(920) 831-8913

Contract Pharmacy Representative

Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770

Signed By Date

4/13/2020

340B Drug Pricing Program Database