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WALGREEN CO.
DSH520177 FROEDTERT MEMORIAL LUTHERAN HOSPITAL
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Covered Entity Details
Entity Name
FROEDTERT MEMORIAL LUTHERAN HOSPITAL
Subdivision Name
FORMERLY JOHN L. DOYNE HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH520177
Entity Address
9200 WEST WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
520177
Participating Start Date
7/1/1996
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 05417
6125 DURAND AVE.
MT PLEASANT, WI 53406
Pharmacy Comments
Contract Details
Approval Date
3/8/2012
Contract Begin Date
3/8/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeffrey Van De Kreeke, CFO
(414) 777-0968
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
3/7/2012
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