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Community Memorial Hospital of Menomonee Falls, Inc. d/b/a ISC Central Hospital 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
Community Memorial Hospital of Menomonee Falls, Inc. d/b/a ISC Central Hospital Pharmacy
Pharmacy Address
N86 W12999 Nightingale way
Suite 1047
Menomonee Falls, WI 53051
Pharmacy Comments
Contract Details
Approval Date
5/23/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Klauck, Senior Vice President, Ancillary Services
(414) 777-1925
Contract Pharmacy Representative
Erick Siegenthaler, Manager, Home Infusion
(262) 532-5124
Signed By Date
5/2/2017
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