Contract Pharmacy Details

DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN
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

DIPLOMAT SPECIALTY PHARMACY OF SOUTHERN

Pharmacy Address

DIPLOMAT SPECIALTY PHARMACY
1809 EXCISE AVENUE
SUITE 204-208
ONTARIO, CA 91761

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

5/18/2018
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
Sandra Barbosa, Pharmacy Manager
(602) 366-4692

Signed By Date

4/8/2016

340B Drug Pricing Program Database