Contract Pharmacy Details

PICK N SAVE PHARMACY #6891
DSH520096 Ascension All Saints Hospital, Inc.

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

PICK N SAVE PHARMACY #6891

Pharmacy Address

2820 S. GREEN BAY RD.
MOUNT PLEASANT, WI 53406

Pharmacy Comments

Contract Details

Approval Date

7/15/2013

Contract Begin Date

10/1/2013

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/5/2022
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Jon Sohn, CFO
(414) 465-3090

Contract Pharmacy Representative

Edward G. Kitz, GVP Legal, Risk and Treasury, G&A
(414) 231-5901

Signed By Date

7/15/2013

340B Drug Pricing Program Database