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ASCENSION WISCONSIN PHARMACY, INC.
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus
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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
ASCENSION WISCONSIN PHARMACY, INC.
Pharmacy Address
DBA/ ASCENSION RX 1106
201 N MAYFAIR RD
WAUWATOSA, WI 53226-4216
Pharmacy Comments
01/15/2014 - Pharmacy name and address correction, changed in error on 3/28/2013, see history for details.
Contract Details
Approval Date
1/7/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Bergmann, President
(920) 831-8913
Contract Pharmacy Representative
Ascension
Kristopher Cyr, Manager Pharmacy Operations
(262) 687-2151
Signed By Date
1/7/2025
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