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HOME CARE PHARMACY
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
HOME CARE PHARMACY
Pharmacy Address
5665 S WESTRIDGE DRIVE
SUITE 100
NEW BERLIN, WI 53151-7954
Pharmacy Comments
Contract Details
Approval Date
10/15/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/5/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Van De Kreeke, Vice President, Finance
(414) 777-0968
Contract Pharmacy Representative
John Teevan, President
(262) 957-5215
Signed By Date
10/15/2013
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