Contract Pharmacy Details

WALGREEN CO.
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Covered Entity Details

Entity Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520009

Entity Address

1506 S. Oneida St.
Appleton, WI 54915

Medicare Provider Number

520009

Participating Start Date

4/1/2012

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

WALGREEN CO.

Pharmacy Address

WALGREENS SPECIALTY PHARMACY #21254
2265 N MAYFAIR RD.
WAUWATOSA, WI 53226

Pharmacy Comments

Contract Details

Approval Date

4/5/2024

Contract Begin Date

7/1/2024

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Michael Bergmann, President
(920) 831-8913

Contract Pharmacy Representative

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

Signed By Date

4/5/2024

340B Drug Pricing Program Database