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OPTUM PHARMACY 701, LLC
DSH520136 Ascension SE Wisconsin Hospital, Inc.
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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
OPTUM PHARMACY 701, LLC
Pharmacy Address
8131 W BOSTIAN RD STE A350
WOODINVILLE, WA 98072-5029
Pharmacy Comments
Contract Details
Approval Date
7/13/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/13/2021
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