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SHOPKO PHARMACY #2031
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
SHOPKO PHARMACY #2031
Pharmacy Address
5300 52ND STREET
KENOSHA, WI 53144-2398
Pharmacy Comments
Contract Details
Approval Date
4/15/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/8/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
James Gresham, Senior Vice President
(414) 874-6277
Contract Pharmacy Representative
Lori Neumann, Manager
(920) 429-5725
Signed By Date
4/15/2016
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