Contract Pharmacy Details

SINA DRUG LLC
DSH520136 Ascension SE Wisconsin Hospital, Inc.

Covered Entity Details

Entity Name

Ascension SE Wisconsin Hospital, Inc.

Subdivision Name

ST. JOSEPH CAMPUS

Type

Disproportionate Share Hospital

340B ID

DSH520136

Entity Address

5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210

Medicare Provider Number

520136

Participating Start Date

4/1/2004

Last Recertification Date

8/27/2024

Pharmacy Details

Pharmacy Name

SINA DRUG LLC

Pharmacy Address

DBA ONCO360
1985 MARCUS AVE STE 120
NEW HYDE PARK, NY 11042

Pharmacy Comments

08/02/2012 corrected name (was OncoMed Pharmacy)

Contract Details

Approval Date

1/12/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/13/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Contract Pharmacy Representative

Onco360
Leo Gray, Director of Pharmacy
(877) 662-6633 Ext: 1207

Signed By Date

1/12/2018

340B Drug Pricing Program Database