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DIPLOMAT SPECIALTY PHARMACY
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
DIPLOMAT SPECIALTY PHARMACY
Pharmacy Address
G3320 BEECHER RD
FLINT, MI 48532-3614
Pharmacy Comments
Contract Details
Approval Date
4/8/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Gresham, Senior Vice President
(414) 874-6277
Contract Pharmacy Representative
Diplomat Specialty Pharmacy
Teri Johnson, Pharmacist
(810) 732-8720
Signed By Date
4/8/2016
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