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WAL-MART PHARMACY 10-2452
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
WAL-MART PHARMACY 10-2452
Pharmacy Address
401 E. CAPITOL DRIVE
MILWAUKEE, WI 53212
Pharmacy Comments
Contract Details
Approval Date
3/5/2012
Contract Begin Date
3/9/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Rhonda Anderson, PRESIDENT & CFO
(414) 270-4850
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
2/27/2012
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