Contract Pharmacy Details

ASCENSION RX 1103
DSH520136 Ascension SE Wisconsin Hospital, Inc.

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 RX 1103

Pharmacy Address

DBA ASCENSION RX 1114
10180 WASHINGTON AVE
STE 102
MOUNT PLEASANT, WI 53177

Pharmacy Comments

Contract Details

Approval Date

1/13/2021

Contract Begin Date

4/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

5/6/2022
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
Kristopher Cyr, Manager Pharmacy Operations
(262) 687-2151

Signed By Date

1/13/2021

340B Drug Pricing Program Database