Contract Pharmacy Details

KMART PHARMACY
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

KMART PHARMACY

Pharmacy Address

5141 DOUGLAS AVENUE
RACINE, WI 53402

Pharmacy Comments

Contract Details

Approval Date

8/1/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/9/2019
Ownership change

Contacts

Covered Entity Signing Official

James Gresham, Senior Vice President
(414) 874-6277

Contract Pharmacy Representative

Beth Zander, Director, Managed Care Services
(847) 286-7661

Signed By Date

8/1/2014

340B Drug Pricing Program Database