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GENOA HEALTHCARE LLC
DSH520177 FROEDTERT MEMORIAL LUTHERAN HOSPITAL
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Covered Entity Details
Entity Name
FROEDTERT MEMORIAL LUTHERAN HOSPITAL
Subdivision Name
FORMERLY JOHN L. DOYNE HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH520177
Entity Address
9200 WEST WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
520177
Participating Start Date
7/1/1996
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
1717 TAYLOR AVE, STE P1
RACINE, WI 53403
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
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925
Contract Pharmacy Representative
Optum
Nancy McCutcheon, SR VP of Strategic Sales
(651) 983-0677
Signed By Date
7/16/2021
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