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WAL-MART PHARMACY 10-3488
DSH520096 Ascension All Saints Hospital, Inc.
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Covered Entity Details
Entity Name
Ascension All Saints Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520096
Entity Address
3801 SPRING STREET
RACINE, WI 53405
Medicare Provider Number
520096
Participating Start Date
4/1/2004
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3488
Pharmacy Address
1901 S MILWAUKEE AVE
BURLINGTON, WI 53105
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/31/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/12/2018
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