Contract Pharmacy Details

WISCONSIN CVS PHARMACY, L.L.C.
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

WISCONSIN CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 08773
3030 W VILLARD AVE
MILWAUKEE, WI 53209

Pharmacy Comments

Contract Details

Approval Date

7/13/2021

Contract Begin Date

10/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/22/2025
Pharmacy closed

Contacts

Covered Entity Signing Official

Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Contract Pharmacy Representative

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

Signed By Date

7/13/2021

340B Drug Pricing Program Database