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 # 02752
15350 WEST BLUEMOUND RD
ELM GROVE, WI 53122

Pharmacy Comments

Contract Details

Approval Date

4/5/2013

Contract Begin Date

7/1/2013

Carve-In Effective Date

Contract Comments

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

4/5/2013

340B Drug Pricing Program Database