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ASCENSION WISCONSIN PHARMACY INC
DSH520136 Ascension SE Wisconsin Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension SE Wisconsin Hospital, Inc.
Subdivision Name
ST. JOSEPH CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH520136
Entity Address
5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210
Medicare Provider Number
520136
Participating Start Date
4/1/2004
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
ASCENSION WISCONSIN PHARMACY INC
Pharmacy Address
DBA/ ASCENSION RX 1116
7400 W RAWSON AVE STE 140
FRANKLIN, WI 53132-8281
Pharmacy Comments
Contract Details
Approval Date
7/8/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
Ascension
Kristopher Cyr, Manager Pharmacy Operations
(262) 687-2151
Signed By Date
7/8/2020
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