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DBA PICK 'N SAVE PHARMACY 6874
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
DBA PICK 'N SAVE PHARMACY 6874
Pharmacy Address
5710 75TH STREET
KENOSHA, WI 53142
Pharmacy Comments
Contract Details
Approval Date
10/7/2015
Contract Begin Date
1/1/2016
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
James Gresham, Senior Vice President
(414) 874-6277
Contract Pharmacy Representative
Edward G. Kitz, GVP Legal, Risk and Treasury, G&A
(414) 231-5901
Signed By Date
10/7/2015
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