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WAL-MART PHARMACY 10-2668
DSH520096 Ascension All Saints Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension All Saints Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520096
Entity Address
3801 SPRING STREET
RACINE, WI 53405
Medicare Provider Number
520096
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2668
Pharmacy Address
3049 SOUTH OAKES ROAD
STURTEVANT, WI 53177
Pharmacy Comments
Contract Details
Approval Date
2/19/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon Sohn, CFO
(414) 465-3090
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/17/2013
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