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ASCENSION RX 1103
DSH520096 Ascension All Saints Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension All Saints Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520096
Entity Address
3801 SPRING STREET
RACINE, WI 53405
Medicare Provider Number
520096
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
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
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