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CYSTIC FIBROSIS SERVICES, LLC
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
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/29/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/30/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Travis D. Andersen, President/CEO
(414) 585-4870
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/29/2017
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