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 # 07259
3855 SOUTH MOORLAND
NEW BERLIN, WI 53151-5225

Pharmacy Comments

Contract Details

Approval Date

4/4/2014

Contract Begin Date

7/1/2014

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

James Gresham, Senior Vice President
(414) 874-6277

Contract Pharmacy Representative

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

Signed By Date

4/4/2014

340B Drug Pricing Program Database