Contract Pharmacy Details

WISCONSIN CVS PHARMACY, L.L.C.
DSH520066 MERCY HEALTH SYSTEM CORPORATION

Covered Entity Details

Entity Name

MERCY HEALTH SYSTEM CORPORATION

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520066

Entity Address

1000 MINERAL POINT AVE
JANESVILLE, WI 53547-5003

Medicare Provider Number

520066

Participating Start Date

4/1/2019

Last Recertification Date

8/30/2023

Entity Termination Date

1/1/2024

Pharmacy Details

Pharmacy Name

WISCONSIN CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 06855
17165 BLUEMOUND RD.
BROOKFIELD, WI 53005

Pharmacy Comments

Contract Details

Approval Date

7/18/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2024
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

7/18/2020

340B Drug Pricing Program Database