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WISCONSIN CVS PHARMACY, L.L.C.
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
WISCONSIN CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 08769
5929 WEST LISBON AVE
MILWAUKEE, WI 53210
Pharmacy Comments
Contract Details
Approval Date
7/16/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/15/2023
Pharmacy closed
Contacts
Covered Entity Signing Official
Jeffrey Van De Kreeke, Vice President, Finance
(414) 777-0968
Contract Pharmacy Representative
Scott Tierney, Senior Director, Payer Relations
(401) 770-2762
Signed By Date
7/16/2013
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