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WAL-MART PHARMACY 10-3322
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
WAL-MART PHARMACY 10-3322
Pharmacy Address
411 PEWAUKEE ROAD
PEWAUKEE, WI 53072
Pharmacy Comments
Contract Details
Approval Date
9/5/2012
Contract Begin Date
9/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon Sohn, CFO
(414) 465-3090
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/21/2012
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