Contract Pharmacy Details

EXPRESS SCRIPTS PHARMACY, INC.
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

EXPRESS SCRIPTS PHARMACY, INC.

Pharmacy Address

DBA EXPRESS SCRIPTS
2040 ROUTE 130 NORTH
BURLINGTON, NJ 08016

Pharmacy Comments

Contract Details

Approval Date

7/16/2021

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

Express Scripts
Gene McCabe, Lead Director, 340B Client Sales
(615) 943-7500

Signed By Date

7/16/2021

340B Drug Pricing Program Database