Covered Entity Details

SCH420071-04 SELF REGIONAL HEALTHCARE (Approved) - information as of 5/27/2025 2:43:09 PM

Main Details

Name

SELF REGIONAL HEALTHCARE

Subdivision Name

Self Regional Healthcare Outpatient Cardiology - Outpatient Cardiology

Type

Sole Community Hospital

Rural

Yes

340B ID

SCH420071-04

Medicare Provider Number

420071

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/11/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/16/2025

Last Recertification Date

Contacts

Authorizing Official

Self Regional Healthcare
Clint Stewart, VP, Chief Financial Officer
(864) 725-4248

Primary Contact

Self Regional Healthcare
Jennifer G Elrod, Director of Pharmacy Services
(864) 725-5774

Addresses

Street Address

421 Epting Avenue
Greenwood, SC 29646

Billing Address
Same as Street Address

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
GA	000103606A	1407887003
FL	092650700	1407887003
SC	305654	1407887003
NC		1407887003

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
SCH420071-01	Child	SCH	SELF REGIONAL HEALTHCARE	MEDICATION MANAGEMENT CLINIC - Medication Management Clinic	102 KATIE CT	GREENWOOD	SC	Active
SCH420071-02	Child	SCH	SELF REGIONAL HEALTHCARE	MONTGOMERY CENTER FOR FAMILY MEDICI - Family Medicine Clinic Primary Care	155 ACADEMY AVE	GREENWOOD	SC	Active
SCH420071-03	Child	SCH	SELF REGIONAL HEALTHCARE	The Imaging Center - Imaging Services	102 Academy Avenue	Greenwood	SC	Active
SCH420071-04	Child	SCH	SELF REGIONAL HEALTHCARE	Self Regional Healthcare Outpatient Cardiology - Outpatient Cardiology	421 Epting Avenue	Greenwood	SC	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Stewart, Clint VP, Chief Financial Officer Self Regional Healthcare 8647254248	4/16/2025 2:54 PM
Details	340B ID	Update	New Registration		SCH420071-04	4/16/2025 2:54 PM
Details	Entity Subname	Update	New Registration	Self Regional Healthcare Outpatient Cardiology	Self Regional Healthcare Outpatient Cardiology - Outpatient Cardiology	4/16/2025 2:54 PM
Dates	Participating Approval Date	Update	New Registration		4/16/2025 2:54:08 PM	4/16/2025 2:54 PM
Details	State	Update	New Registration	Pending	Approved	4/16/2025 2:54 PM
Dates	Signed By Date	Update	New Registration		4/11/2025 12:37:57 PM	4/16/2025 2:54 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/16/2025 2:54 PM
Addresses	Main Address	Insert	New Registration		421 Epting Avenue Greenwood, SC 29646	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		000103606A	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		GA	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		092650700	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		FL	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		305654	4/11/2025 11:06 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		SC	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407887003	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		GA	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407887003	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		FL	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407887003	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		NC	4/11/2025 11:06 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1407887003	4/11/2025 11:06 AM
Medicaid Billing	NPI: State	Insert	New Registration		SC	4/11/2025 11:06 AM
Contacts	Primary Contact	Insert	New Registration		Elrod, Jennifer G Director of Pharmacy Services Self Regional Healthcare 8647255774	4/11/2025 11:06 AM
Contacts	Authorizing Official	Insert	New Registration		Stewart, Clint VP, Chief Financial Officer Self Regional Healthcare 8647254248	4/11/2025 11:06 AM
Details	Assistance Received From Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Assistance Received To Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Last Recertification Date	Insert	New Registration			4/11/2025 11:06 AM
Details	Grant Number	Insert	New Registration			4/11/2025 11:06 AM
Details	340B ID	Insert	New Registration			4/11/2025 11:06 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/11/2025 11:06 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/11/2025 11:06 AM
Details	Medicare Provider Number	Insert	New Registration		420071	4/11/2025 11:06 AM
Details	Entity Name	Insert	New Registration		SELF REGIONAL HEALTHCARE	4/11/2025 11:06 AM
Details	NOFO Number	Insert	New Registration			4/11/2025 11:06 AM
Details	Program Code	Insert	New Registration		SCH	4/11/2025 11:06 AM
Details	Entity Subname	Insert	New Registration		Self Regional Healthcare Outpatient Cardiology	4/11/2025 11:06 AM
Dates	Participating Approval Date	Insert	New Registration			4/11/2025 11:06 AM
Details	State	Insert	New Registration		Pending	4/11/2025 11:06 AM
Dates	Registration Date	Insert	New Registration		4/11/2025 11:06:35 AM	4/11/2025 11:06 AM
Dates	Signed By Date	Insert	New Registration			4/11/2025 11:06 AM
Dates	Start Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Comments	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Effective Date	Insert	New Registration			4/11/2025 11:06 AM
Terminations	Termination Reason	Insert	New Registration			4/11/2025 11:06 AM