Contract Pharmacy Details

SAINT JOSEPH'S HOSP OTPA PHARM
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Covered Entity Details

Entity Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520009

Entity Address

1506 S. Oneida St.
Appleton, WI 54915

Medicare Provider Number

520009

Participating Start Date

4/1/2012

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

SAINT JOSEPH'S HOSP OTPA PHARM

Pharmacy Address

DBA ASCENSION WISCONSIN PHARMACY #701
1901 WESTWOOD CENTER BLVD
WAUSAU, WI 54401

Pharmacy Comments

Contract Details

Approval Date

10/14/2013

Contract Begin Date

1/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Travis Andersen, President
(920) 831-8912

Contract Pharmacy Representative

Vanessa Freitag, Director of Pharmacy
(715) 389-5302

Signed By Date

10/14/2013

340B Drug Pricing Program Database