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HOOK-SUPERX, L.L.C.
DSH520051 COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
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Covered Entity Details
Entity Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
Subdivision Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE
Type
Disproportionate Share Hospital
340B ID
DSH520051
Entity Address
2323 N LAKE DRIVE
MILWAUKEE, WI 53211-4508
Medicare Provider Number
520051
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
HOOK-SUPERX, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06648
655 S. US HIGHWAY 31
GREENWOOD, IN 46142
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
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/13/2021
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