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WISCONSIN CVS PHARMACY, L.L.C.
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
WISCONSIN CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY # 2933
3710 57TH AVE.
KENOSHA, WI 53144
Pharmacy Comments
Contract Details
Approval Date
7/15/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon Sohn, CFO
(414) 465-3090
Contract Pharmacy Representative
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
7/15/2013
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