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ASCENSION NE WISCONSIN
CAH521317-00 Ascension Calumet Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension Calumet Hospital, Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521317-00
Entity Address
614 MEMORIAL DRIVE
CHILTON, WI 53014
Medicare Provider Number
521317
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
ASCENSION NE WISCONSIN
Pharmacy Address
DBA ASCENSION NE WISCONSIN-ST ELIZABETH
1506 S ONEIDA ST
APPLETON, WI 54915
Pharmacy Comments
Contract Details
Approval Date
10/20/2011
Contract Begin Date
10/1/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/11/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
TIMOTHY J. RICHMAN, PRESIDENT AND CEO
(920) 849-7550
Contract Pharmacy Representative
Travis Anderson, President
(920) 831-8912
Signed By Date
10/1/2011
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