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ASPIRUS STANLEY HOSPITAL
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus
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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
ASPIRUS STANLEY HOSPITAL
Pharmacy Address
1120 PINE ST
STANLEY, WI 54768
Pharmacy Comments
Contract Details
Approval Date
4/18/2016
Contract Begin Date
7/1/2016
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
Monica Hilt, Regional VP And Hospital President
(920) 831-8913
Contract Pharmacy Representative
Justin Guthman, Director of Pharmacy
(715) 387-9915
Signed By Date
4/18/2016
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