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ASCENSION WISCONSIN PHARMACY, INC.
DSH520051 COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
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Covered Entity Details
Entity Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE, INC
Subdivision Name
COLUMBIA ST MARYS HOSPITAL MILWAUKEE
Type
Disproportionate Share Hospital
340B ID
DSH520051
Entity Address
2323 N LAKE DRIVE
MILWAUKEE, WI 53211-4508
Medicare Provider Number
520051
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
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
1/10/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Andre Storey, President
(414) 585-1374
Contract Pharmacy Representative
Ascension
Kristopher Cyr, Manager Pharmacy Operations
(262) 687-2151
Signed By Date
1/10/2025
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