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AFFILIATED HEALTH SERVICES, INC.
DSH520051 COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
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Covered Entity Details
Entity Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
Subdivision Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE
Type
Disproportionate Share Hospital
340B ID
DSH520051
Entity Address
2323 N LAKE DRIVE
MILWAUKEE, WI 53211-4508
Medicare Provider Number
520051
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
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
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
Ascension Michigan Pharmacy
Deborah Sopo, Pharmacy Manager
(248) 865-3770
Signed By Date
4/13/2020
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