Covered Entity Details

DSH420018C PRISMA HEALTH RICHLAND HOSPITAL (Active) - information as of 6/19/2025 11:54:03 PM

Main Details

Name

PRISMA HEALTH RICHLAND HOSPITAL

Subdivision Name

Children's Hospital Outpatient Center

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH420018C

Medicare Provider Number

420018

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2012

Participating Start Date

1/1/2013

Participating Approval Date

12/17/2012

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Prisma Health
William Anthony Jackson, Market CEO Midlands
(803) 389-6598

Primary Contact

Prisma Health
Abigail Bouknight, Manager 340B
(803) 920-3041

Addresses

Street Address

9 Medical Park Drive
Suite 300
Columbia, SC 29203

Billing Address

Prisma Health
PO Box 402121
Atlanta, GA 30384

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
10/22/12 David Lee has the authority to act on behalf of the hospital and enter the hospital into a legal agreement with the Federal Government.	12/17/2012

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
SC	387175	1154373843,1558576280,1487868097
NC	387175	1154373843,1558576280,1487868097
GA	387175	1154373843,1558576280,1487868097

Shipping Addresses

Shipping Address 1

Prisma Health Richland Hospital Pharmacy
5 Richland Medical Park Dr
Department of Pharmacy, 1st Floor
Columbia, SC 29203

Shipping Address 2

Prisma Health Compounding and Consolidated Service Center
1071 Holland Road
Simpsonville, SC 29681

Shipping Address 3

Prisma Health Children's Hospital Outpatient Center
9Richland Medical Park Drive
Suite 300
Columbia, SC 29203

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
DSH420018C	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Children's Hospital Outpatient Center	9 Medical Park Drive	Columbia	SC	Active
DSH420018D	Child	DSH	Palmetto Richland	Palmetto Health Ortho Center	1801 Sunset Drive	Columbia	SC	Terminated
DSH420018E	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Palmetto Health Women's Center	1801 Sunset Drive	Columbia	SC	Active
DSH420018F	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	PH Internal Medicine Center	1801 Sunset Drive	Columbia	SC	Active
DSH420018G	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Prisma Health Infusion Center	3010 Farrow Road	Columbia	SC	Active
DSH420018H	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Senior Primary Care	3010 Farrow Road	Columbia	SC	Active
DSH420018J	Child	DSH	Palmetto Richland	Senior Primary Care - Parkridge	100 Palmetto Health Parkway	Columbia	SC	Terminated
DSH420018K	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Family Practice	3209 Colonial Drive	Columbia	SC	Active
DSH420018M	Child	DSH	PALMETTO RICHLAND	Palmetto Health Richland Springs	11 Medical Park Drive	Columbia	SC	Terminated
DSH420018N	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	PSC Lexington County	700 Knox Abbott Drive	West Columbia	SC	Terminated
DSH420018P	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	PSC Laurel	PSC Laurel	Columbia	SC	Terminated
DSH420018Q	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	PSC Shandon	PSC Shandon	Columbia	SC	Terminated
DSH420018R	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	PSC White Rock	PSC White Rock	White Rock	SC	Terminated
DSH420018T	Child	DSH	Palmetto Richland	Celia Saxon Health Center	2133 Walker Solomon Way	Columbia	SC	Terminated
DSH420018U	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Prisma Health Cancer Institute - Columbia	14 Richland Medical Park	Columbia	SC	Active
DSH420018V	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Prisma Health Pediatric Pulmonology - Pulmonology	9 Richland Medical Park Drive	Columbia	SC	Active
DSH420018W	Child	DSH	PRISMA HEALTH RICHLAND HOSPITAL	Pediatric Hematology and Oncology - Hematology and Oncology	7 Richland Medical Park Drive	Columbia	SC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Update	Change Request	Prisma Health Children's Hospital Outpatient Center 14 Richland Medical Park Drive Suite 400 Columbia, SC 29203	Prisma Health Children's Hospital Outpatient Center 9Richland Medical Park Drive Suite 300 Columbia, SC 29203	2/7/2025 12:31 PM
Addresses	Main Address	Update	Change Request	14 Medical Park Drive Suite 400 Columbia, SC 29203	9 Medical Park Drive Suite 300 Columbia, SC 29203	2/7/2025 12:31 PM
Contacts	Authorizing Official	Update	Change Request	Bundy, Michael Chief Executive Officer Prisma Health Baptist 8032965782	Jackson, William Anthony Market CEO Midlands Prisma Health 8033896598	12/4/2024 9:07 AM
Addresses	Shipping Address	Insert	Recertification		Prisma Health Compounding and Consolidated Service Center 1071 Holland Road Simpsonville, SC 29681	9/4/2024 11:38 AM
Addresses	Shipping Address	Insert	Recertification		Prisma Health Children's Hospital Outpatient Center 14 Richland Medical Park Drive Suite 400 Columbia, SC 29203	9/4/2024 11:38 AM
Addresses	Billing Address	Update	Recertification	Prisma Health Richland Hospital Pharmacy 5 Richland Medical Park Dr Columbia, SC 29203	Prisma Health PO Box 402121 Atlanta, GA 30384	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	232488 (SC)		9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	232488 (GA)		9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	232488 (NC)		9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		387175	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		SC	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		387175	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		387175	9/4/2024 11:38 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1558576280	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487868097	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1558576280	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487868097	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1558576280	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2024 11:38 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487868097	9/4/2024 11:38 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/4/2024 11:38 AM
Details	Last Recertification Date	Update	Recertification	9/11/2023 7:05:01 AM	9/4/2024 11:38:32 AM	9/4/2024 11:38 AM
Contacts	Primary Contact	Update	PC Change Request	Bair, Jennifer Davis Director of Pharmacy Prisma Health 8034343769	Bouknight, Abigail Manager 340B Prisma Health 8039203041	10/16/2023 1:20 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2023 7:05 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		232488	9/11/2023 7:05 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/11/2023 7:05 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2023 7:05 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		232488	9/11/2023 7:05 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/11/2023 7:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154373843	9/11/2023 7:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/11/2023 7:05 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154373843	9/11/2023 7:05 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/11/2023 7:05 AM
Details	Last Recertification Date	Update	Recertification	8/30/2022 9:07:37 AM	9/11/2023 7:05:01 AM	9/11/2023 7:05 AM
Details	Last Recertification Date	Update	Recertification	8/27/2021 10:12:21 AM	8/30/2022 9:07:37 AM	8/30/2022 9:07 AM
Contacts	Authorizing Official	Update	Change Request	Cofield, Robert Haarbauer Chief Executive Officer Prisma Health Richland Hospital 8034343750	Bundy, Michael Chief Executive Officer Prisma Health Baptist 8032965782	5/18/2022 6:46 AM
Addresses	Shipping Address	Delete	Recertification	Palmetto Health Pharmacy 10MP 14 Richland Medical Park Dr Columbia, SC 29203		8/27/2021 10:12 AM
Addresses	Shipping Address	Insert	Recertification		Prisma Health Richland Hospital Pharmacy 5 Richland Medical Park Dr Department of Pharmacy, 1st Floor Columbia, SC 29203	8/27/2021 10:12 AM
Addresses	Billing Address	Update	Recertification	Palmetto Health Pharmacy 10MP 14 Richland Medical Park Dr Columbia, SC 29203	Prisma Health Richland Hospital Pharmacy 5 Richland Medical Park Dr Columbia, SC 29203	8/27/2021 10:12 AM
Details	Last Recertification Date	Update	Recertification	9/10/2020 5:42:06 PM	8/27/2021 10:12:21 AM	8/27/2021 10:12 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1154373843	9/10/2020 5:42 PM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/10/2020 5:42 PM
Medicaid Billing	NPI: Number	Delete	Recertification	1487868097 ( )		9/10/2020 5:42 PM
Details	Last Recertification Date	Update	Recertification	8/26/2019 2:08:29 PM	9/10/2020 5:42:06 PM	9/10/2020 5:42 PM
Contacts	Authorizing Official	Update	Change Request	Johnson, Paul Interim Chief Executive Officer Prisma Health Richland Hospital 8034344500	Cofield, Robert Haarbauer Chief Executive Officer Prisma Health Richland Hospital 8034343750	8/14/2020 7:51 AM
Addresses	Shipping Address	Insert	Change Request		Palmetto Health Pharmacy 10MP 14 Richland Medical Park Dr Columbia, SC 29203	3/5/2020 3:17 PM
Addresses	Billing Address	Update	Change Request	Palmetto Health Pharmacy 10MP 10 Medical Park Drive Columbia, SC 29203	Palmetto Health Pharmacy 10MP 14 Richland Medical Park Dr Columbia, SC 29203	3/5/2020 3:17 PM
Addresses	Shipping Address	Delete	Change Request	Palmetto Health Pharmacy 10MP 10 Medical Park Drive Columbia, SC 29203		3/5/2020 3:17 PM
Contacts	Primary Contact	Update	Change Request	BAIR, JENNIFER DAVIS System Director of Pharmacy Prisma Health 8034343769	Bair, Jennifer Davis Director of Pharmacy Prisma Health 8034343769	3/5/2020 3:17 PM
Contacts	Authorizing Official	Update	Change Request	Hamm, Jay D Chief Executive Officer Prisma Health Richland Hospital 8034344688	Johnson, Paul Interim Chief Executive Officer Prisma Health Richland Hospital 8034344500	1/15/2020 1:04 PM
Contacts	Authorizing Official	Update	Change Request	Hamm, Jay Chief Operating Officer Palmetto Health Richland 8034344688	Hamm, Jay D Chief Executive Officer Prisma Health Richland Hospital 8034344688	10/25/2019 1:23 PM
Details	Entity Name	Update	Change Request	Palmetto Richland	PRISMA HEALTH RICHLAND HOSPITAL	10/25/2019 1:23 PM
Contacts	Primary Contact	Update	Profile Change Request	BAIR, JENNIFER DAVIS System Director of Pharmacy Palmetto Health 8034343769	BAIR, JENNIFER DAVIS System Director of Pharmacy Prisma Health 8034343769	10/4/2019 6:47 PM
Details	Last Recertification Date	Update	Recertification	9/6/2018 11:39:24 AM	8/26/2019 2:08:29 PM	8/26/2019 2:08 PM
Details	Last Recertification Date	Update	Recertification	12/5/2017 5:47:46 PM	9/6/2018 11:39:24 AM	9/6/2018 11:39 AM
Contacts	Authorizing Official	Update	Change Request	Cunningham, Benjamin Martin System VP - Finance Palmetto Health 8032962448	Hamm, Jay Chief Operating Officer Palmetto Health Richland 8034344688	2/1/2018 8:37 AM
Details	Last Recertification Date	Update	Recertification	8/29/2016 12:00:00 AM	12/5/2017 5:47:46 PM	12/5/2017 5:47 PM
Contacts	Primary Contact	Update	Profile Change Request	BAIR, JENNIFER DAVIS Pharmacy Manager Palmetto Health 8034343769	BAIR, JENNIFER DAVIS System Director of Pharmacy Palmetto Health 8034343769	10/18/2017 10:52 AM
Contacts	Primary Contact	Insert	Change Request		BAIR, JENNIFER DAVIS Pharmacy Manager Palmetto Health 8034343769	10/15/2017 9:24 PM
Contacts	Authorizing Official	Insert	Change Request		Cunningham, Benjamin Martin System VP - Finance Palmetto Health 8032962448	10/2/2017 7:25 AM
Details	Entity Name	Update	Change Request	PALMETTO RICHLAND	Palmetto Richland	10/2/2017 7:25 AM
Contacts	Signed By	Insert			Lee, David F. Director of Financial Forecasting 8032963632	4/20/2017 7:01 PM
Addresses	Main Address	Insert			14 Medical Park Drive Suite 400 Columbia, SC 29203	4/20/2017 7:01 PM
Addresses	Billing Address	Insert			Palmetto Health Pharmacy 10MP 10 Medical Park Drive Columbia, SC 29203	4/20/2017 7:01 PM
Addresses	Shipping Address	Insert			Palmetto Health Pharmacy 10MP 10 Medical Park Drive Columbia, SC 29203	4/20/2017 7:01 PM
Details	Last Recertification Date	Update		8/24/2015 12:00:00 AM	8/29/2016 12:00:00 AM	8/29/2016 9:21 AM
Details	Last Recertification Date	Update		8/15/2014 12:00:00 AM	8/24/2015 12:00:00 AM	8/24/2015 2:35 PM
Details	Last Recertification Date	Update		8/22/2013 6:10:13 PM	8/15/2014 12:00:00 AM	8/15/2014 12:47 PM
Details	Last Recertification Date	Update			8/22/2013 6:10:13 PM	8/22/2013 6:10 PM
Details	340B ID	Update		IS-DR-DSH420018C	DSH420018C	12/17/2012 12:18 PM
Details	Entity Name	Update		PALMETTO RICHLAND MEMORIAL HOSPITAL	PALMETTO RICHLAND	12/17/2012 12:18 PM
Dates	Participating Approval Date	Update			12/17/2012 12:00:00 AM	12/17/2012 12:18 PM
Details	State	Update		Pending	Active	12/17/2012 12:18 PM
Dates	Start Date	Update			1/1/2013 12:00:00 AM	12/17/2012 12:18 PM
Details	Comments Public	Insert			10/22/12 David Lee has the authority to act on behalf of the hospital and enter the hospital into a legal agreement with the Federal Government.	12/17/2012 8:16 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-DR-DSH420018C	10/23/2012 3:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	10/11/2012 3:34 PM
Medicaid Billing	Medicaid: Number	Insert			232488	10/11/2012 3:34 PM
Medicaid Billing	Medicaid: State	Insert			SC	10/11/2012 3:34 PM
Medicaid Billing	NPI: Number	Insert			1487868097	10/11/2012 3:34 PM
Details	Last Recertification Date	Insert				10/11/2012 3:34 PM
Details	Grant Number	Insert				10/11/2012 3:34 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	10/11/2012 3:34 PM
Details	Is Authorizing Official EHB Data	Insert				10/11/2012 3:34 PM
Dates	Last Date That 340B Drugs Purchased	Insert				10/11/2012 3:34 PM
Details	Medicare Provider Number	Insert			420018	10/11/2012 3:34 PM
Details	Entity Name	Insert			PALMETTO RICHLAND MEMORIAL HOSPITAL	10/11/2012 3:34 PM
Details	Program Code	Insert			DSH	10/11/2012 3:34 PM
Details	Entity Subname	Insert			Children's Hospital Outpatient Center	10/11/2012 3:34 PM
Dates	Participating Approval Date	Insert				10/11/2012 3:34 PM
Details	State	Insert			Pending	10/11/2012 3:34 PM
Dates	Registration Date	Insert			10/11/2012 12:00:00 AM	10/11/2012 3:34 PM
Dates	Signed By Date	Insert			10/11/2012 12:00:00 AM	10/11/2012 3:34 PM
Dates	Start Date	Insert				10/11/2012 3:34 PM
Terminations	Termination Comments	Insert				10/11/2012 3:34 PM
Terminations	Termination Date	Insert				10/11/2012 3:34 PM
Terminations	Termination Effective Date	Insert				10/11/2012 3:34 PM
Terminations	Termination Reason	Insert				10/11/2012 3:34 PM