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WALGREENS SPECIALTY PHARMACY, LLC
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus
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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
WALGREENS SPECIALTY PHARMACY, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #15438
41460 HAGGERTY CIR S
CANTON, MI 48188
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
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