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ASCENSION WISCONSIN PHARMACY, INC.
DSH520136 Ascension SE Wisconsin Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension SE Wisconsin Hospital, Inc.
Subdivision Name
ST. JOSEPH CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH520136
Entity Address
5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210
Medicare Provider Number
520136
Participating Start Date
4/1/2004
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
ASCENSION WISCONSIN PHARMACY, INC.
Pharmacy Address
DBA/ ASCENSION RX 1103
5000 W CHAMBERS ST RM 1801
ROOM 1801
MILWAUKEE, WI 53210-1650
Pharmacy Comments
01/15/2014 - Pharmacy name and address correction, changed in error on 3/28/2013, see history for details.
Contract Details
Approval Date
6/17/2008
Contract Begin Date
6/17/2008
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DEBRA STANDRIDGE, PRESIDENT
(414) 447-2847
Contract Pharmacy Representative
James Gresham, Senior Vice President
(414) 874-6277
Signed By Date
6/3/2008
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