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ASCENSION WISCONSIN PHARMACY, INC.
DSH520136B WHEATON FRANCISCAN, INC.
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Covered Entity Details
Entity Name
WHEATON FRANCISCAN, INC.
Subdivision Name
WAUWATOSA CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH520136B
Entity Address
201 N MAYFAIR ROAD
WAUWATOSA, WI 53226
Medicare Provider Number
520136
Outpatient Facility Provider Number
Participating Start Date
11/20/2009
Last Recertification Date
11/29/2017
Entity Termination Date
4/1/2018
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
12/4/2009
Contract Begin Date
12/4/2009
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DEBRA STANDRIDGE, PRESIDENT
(414) 447-2847
Contract Pharmacy Representative
James Gresham, Senior Vice President
(414) 874-6277
Signed By Date
12/2/2009
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