Contract Pharmacy Details

ACARIAHEALTH PHARMACY #11, INC
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

ACARIAHEALTH PHARMACY #11, INC

Pharmacy Address

1311 W SAM HOUSTON PKWY N STE 130
HOUSTON, TX 77043-4015

Pharmacy Comments

Contract Details

Approval Date

4/11/2018

Contract Begin Date

7/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/4/2019
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

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

Contract Pharmacy Representative

Acaria Health
Jeril Kurian, Pharmacist In Charge
(800) 511-5144

Signed By Date

4/11/2018

340B Drug Pricing Program Database