Contract Pharmacy Details

CYSTIC FIBROSIS SERVICES, LLC
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Covered Entity Details

Entity Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520009

Entity Address

1506 S. Oneida St.
Appleton, WI 54915

Medicare Provider Number

520009

Participating Start Date

4/1/2012

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

CYSTIC FIBROSIS SERVICES, LLC

Pharmacy Address

DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033

Pharmacy Comments

Contract Details

Approval Date

4/15/2021

Contract Begin Date

7/1/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Monica Ann Hilt, President
(920) 831-8913

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

4/15/2021

340B Drug Pricing Program Database