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WALGREEN CO.
PED523300-00 CHILDREN'S HOSPITAL OF WISCONSIN, INC.
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Covered Entity Details
Entity Name
CHILDREN'S HOSPITAL OF WISCONSIN, INC.
Subdivision Name
Type
Children's Hospital
340B ID
PED523300-00
Entity Address
9000 W. WISCONSIN AVENUE
MILWAUKEE, WI 53226
Medicare Provider Number
523300
Participating Start Date
4/1/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #13683
1720 W. WASHINGTON ST.
WEST BEND, WI 53095-2311
Pharmacy Comments
Contract Details
Approval Date
1/6/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marc H. Gorelick, EXECUTIVE VICE PRESIDENT
(414) 266-2648
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/6/2017
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