Contract Pharmacy Details

WALGREEN CO.
DSH520136 Ascension SE Wisconsin Hospital, Inc.

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

WALGREEN CO.

Pharmacy Address

DBA: WALGREENS #12783
2826 N. MARTIN LUTHER KING DR.
MILWAUKEE, WI 53212-2314

Pharmacy Comments

Contract Details

Approval Date

10/31/2012

Contract Begin Date

10/31/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/5/2024
Pharmacy closed

Contacts

Covered Entity Signing Official

Jon Sohn, CFO
(414) 465-3090

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/31/2012

340B Drug Pricing Program Database