Covered Entity Details

DSH420078AA Prisma Health GREENVILLE MEMORIAL HOSPITAL (Active) - information as of 6/14/2025 10:09:25 AM

Main Details

Name

Prisma Health GREENVILLE MEMORIAL HOSPITAL

Subdivision Name

Prisma Health Cancer Institute - Eastside

Type

Disproportionate Share Hospital

Rural

340B ID

DSH420078AA

Medicare Provider Number

420078

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/15/2013

Participating Start Date

7/1/2013

Participating Approval Date

6/11/2013

Last Recertification Date

9/4/2024

Contacts

Authorizing Official

Prisma Greenville Memorial
Barrett Ludley, CFO
(864) 455-6405

Primary Contact

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

Addresses

Street Address

65 International Drive
Greenville, SC 29615

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
5/17/13 - Entity submitted supporting documents, reviewed registrations and forwarded to IS for approval. 5/9/13 - Delete, no supporting documents submitted.	05/17/2013
5/9/13 - Delete, no supporting documents submitted.	05/09/2013

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	354643	1679029771,1770039885
NC	354643	1679029771,1770039885
GA	354643	1679029771,1770039885

Shipping Addresses

Shipping Address 1

Prisma Health Cancer Insititute - Eastside
65 International Dr
Greenville, SC 29615

Shipping Address 2

Prisma Health Pharmacy Consolidated Service Center
1071 Holland Rd
Simpsonville, SC 29681

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
DSH420078A	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Physical Therapy O/H-RCP	701 Grove Road	Greenville	SC	Terminated
DSH420078AA	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute - Eastside	65 International Drive	Greenville	SC	Active
DSH420078AB	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Insititute - Seneca	131 Lila Doyle Drive	Seneca	SC	Active
DSH420078AC	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute - Faris	900 West Faris Road	Greenville	SC	Active
DSH420078AD	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc-greer medical oncology	325 medical parkway suite 200c	greer	SC	Terminated
DSH420078AE	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute- Greer	340 Medical Parkway	Greer	SC	Active
DSH420078AF	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	Cancer Institute- Andrews	200 andrews st., suite 100	greenville	SC	Terminated
DSH420078AG	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute - Easley	200 Fleetwood Dr.	Easley	SC	Active
DSH420078AH	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute - Grove	3 Butternut Drive	Greenville	SC	Active
DSH420078AJ	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH, Eastside	65 International Drive	Greenville	SC	Terminated
DSH420078AK	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH - Seneca	701 grove rd	greenville	SC	Terminated
DSH420078AL	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH - faris	701 grove rd	greenville	SC	Terminated
DSH420078AM	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc- a dept of GMH- Greer Medical	701 grove rd	greenville	SC	Terminated
DSH420078AN	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH -Greer Radiation Oncology	701 grove rd	greenville	SC	Terminated
DSH420078AP	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH - easley	109 Fleetwood Dr. Suite A	Easley	SC	Terminated
DSH420078AQ	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH - Andrews	701 grove rd	greenville	SC	Terminated
DSH420078AR	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc - a dept of GMH - Spartanburg	701 grove rd	greenville	SC	Terminated
DSH420078AS	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Pediatric Hematology/Oncology	900 West Faris Road	Greenville	SC	Active
DSH420078AT	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Infusion Center	900 West Faris Road	GREENVILLE	SC	Active
DSH420078AU	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health GI Lab Services	890 West Faris Road	Greenville	SC	Active
DSH420078AV	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	GHS Center for Pediatric Medicine / Ferlauto Center for Medically Complex Children	200 Patewood Drive	Greenville	SC	Active
DSH420078AW	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cardiovascular Clinic	3 Butternut Drive	Greenville	SC	Active
DSH420078AX	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cancer Institute - Laurens	22725 Highway 76 East	Clinton	SC	Active
DSH420078AY	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Acadia Allergy and Immunology - Allergy and Immunology	10 Halton Green Way	Greenville	SC	Active
DSH420078AZ	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Gastroenterology and Liver Center - Gastroenterology	890 West Faris Road	Greenville	SC	Active
DSH420078B	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Greenville Radiology - Radioisotope	1210 W. Faris Road	Greenville	SC	Active
DSH420078BA	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Infusion Center - Greer - Infusion	340 Medical Parkway	Greer	SC	Active
DSH420078BB	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Infusion Center - Oconee - Infusion	298 Memorial Drive	Seneca	SC	Active
DSH420078BC	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Rheumatology Specialists - Rheumatology	155B Halton Village Circle	Greenville	SC	Active
DSH420078BD	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Infusion Center - Hillcrest - Infusion	727 SE Main Street	Simpsonville	SC	Active
DSH420078BE	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Pediatrics - Verdae - Pediatric Medicine	905 Verdae Blvd	Greenville	SC	Active
DSH420078BF	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Center for Family Medicine - Greenville - Family Medicine	29 N. Academy Street	Greenville	SC	Active
DSH420078C	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Greenville Radiology-MRI	1210 West Faris Rd.	Greenville	SC	Active
DSH420078D	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Greenville Radiology-CT	1210 West Faris Rd	Greenville	SC	Active
DSH420078E	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Greenville Radiology-Mammography	1210 West Faris Rd.	Greenville	SC	Active
DSH420078F	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Greenville Radiology-Diag Svc	1210 West Faris Rd.	Greenville	SC	Active
DSH420078G	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cross Creek Surgery Center	9 Doctors Drive	Greenville	SC	Active
DSH420078H	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cross Creek Surgery Center-RR	9 Doctors Drive	Greenville	SC	Terminated
DSH420078J	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Cross Creek Surgery Center-ANES	9 Doctors Drive	Greenville	SC	Terminated
DSH420078K	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	CV Diag Svc Radioisotope - GMH	3 Butternut Drive	Greenville	SC	Active
DSH420078L	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	CV Diag SVC ECHO-GMH	3 Butternut Drive	Greenville	SC	Active
DSH420078M	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Center for Pediatric Medicine	5 West Main Street	Greenville	SC	Active
DSH420078N	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Center for Pediatric Medicine -Infusion	905 Verdae Blvd	Greenville	SC	Active
DSH420078P	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	center for pediatric and internal medicine-west	5 West Main Street	Greenville	SC	Active
DSH420078Q	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Center for Pediatric Medicine - North Greenville	807 North Main Street	Travelers Rest	SC	Active
DSH420078R	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Partial Hospitalization-MIP	701 Grove Road	Greenville	SC	Active
DSH420078S	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Prisma Health Surgical Orthopedic Clinic	13 Edgewood Drive	Greenville	SC	Active
DSH420078T	Child	DSH	Greenville Memorial Hospital	Surgical Orthopedic Clinic - N Greenville	807 North Main St	Travelers Rest	SC	Terminated
DSH420078U	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	OB/GYN Clinic	1120 Grove Road	Greenville	SC	Active
DSH420078V	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Internal Medicine Clinic	876 W. Faris Rd.	Greenville	SC	Active
DSH420078W	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Center for Family Medicine	877 W. Faris Rd Suite A	Greenville	SC	Active
DSH420078X	Child	DSH	Prisma Health GREENVILLE MEMORIAL HOSPITAL	Cancer Institute - Spartanburg	2400 Boiling Springs Rd	Boiling Springs	SC	Active
DSH420078Z	Child	DSH	GREENVILLE MEMORIAL HOSPITAL	ccc grove	3 butternut drive , suite b	greenville	SC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Addresses	Shipping Address	Delete	Group Change Request	The Blood Connection Cellular Therapy Processing Lab 1099 Bracken Road Piedmont, SC 29673		5/28/2025 6:10 AM
Addresses	Billing Address	Insert	Recertification		Prisma Health PO Box 402121 Atlanta, GA 30384	9/4/2024 10:32 AM
Addresses	Shipping Address	Insert	Recertification		Prisma Health Cancer Insititute - Eastside 65 International Dr Greenville, SC 29615	9/4/2024 10:32 AM
Addresses	Shipping Address	Insert	Recertification		Prisma Health Pharmacy Consolidated Service Center 1071 Holland Rd Simpsonville, SC 29681	9/4/2024 10:32 AM
Addresses	Shipping Address	Delete	Recertification	CCC-eastside 65 International Dr Greenville, SC 29615		9/4/2024 10:32 AM
Addresses	Shipping Address	Delete	Recertification	GHS Pharmacy Consolidated Service Center 1071 Holland Rd Simpsonville, SC 29681		9/4/2024 10:32 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	111717 (SC)		9/4/2024 10:32 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	111717 (NC)		9/4/2024 10:32 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	111717 (GA)		9/4/2024 10:32 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649726738 (SC)		9/4/2024 10:32 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649726738 (NC)		9/4/2024 10:32 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649726738 (GA)		9/4/2024 10:32 AM
Details	Last Recertification Date	Update	Recertification	9/1/2023 2:23:02 PM	9/4/2024 10:32:49 AM	9/4/2024 10:32 AM
Details	Entity Subname	Update	Recertification	ccc-eastside	Prisma Health Cancer Institute - Eastside	9/4/2024 10:32 AM
Contacts	Primary Contact	Update	Group Change Request	carros, sam george Supply Chain and 340B Pharmacist Prisma Health GREENVILLE MEMORIAL HOSPITAL 8645223821	Bouknight, Abigail Manager 340B Prisma Health 8039203041	10/17/2023 8:08 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111717	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		SC	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111717	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NC	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		111717	9/7/2023 10:24 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		GA	9/7/2023 10:24 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1770039885	9/7/2023 10:24 AM
Medicaid Billing	NPI: State	Insert	Change Request		SC	9/7/2023 10:24 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1770039885	9/7/2023 10:24 AM
Medicaid Billing	NPI: State	Insert	Change Request		NC	9/7/2023 10:24 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1770039885	9/7/2023 10:24 AM
Medicaid Billing	NPI: State	Insert	Change Request		GA	9/7/2023 10:24 AM
Details	Last Recertification Date	Update	Recertification	9/8/2022 9:12:21 AM	9/1/2023 2:23:02 PM	9/1/2023 2:23 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	354643 (FL)		11/11/2022 4:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	354643 (TN)		11/11/2022 4:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	354643 (NY)		11/11/2022 4:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	354643 (NJ)		11/11/2022 4:50 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	354643 (PA)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649726738 (FL)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679029771 (FL)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649726738 (TN)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679029771 (TN)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649726738 (NY)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679029771 (NY)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649726738 (NJ)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679029771 (NJ)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1649726738 (PA)		11/11/2022 4:50 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1679029771 (PA)		11/11/2022 4:50 PM
Details	Last Recertification Date	Update	Recertification	9/3/2021 8:00:20 AM	9/8/2022 9:12:21 AM	9/8/2022 9:12 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 10:45:18 AM	9/3/2021 8:00:20 AM	9/3/2021 8:00 AM
Contacts	Authorizing Official	Update	Change Request	Agnew, James Scott CEO Prisma Health Greenville Memorial 8644555286	Ludley, Barrett CFO Prisma Greenville Memorial 8644556405	8/18/2021 12:52 PM
Addresses	Shipping Address	Insert	Change Request		The Blood Connection Cellular Therapy Processing Lab 1099 Bracken Road Piedmont, SC 29673	5/7/2021 7:39 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		FL	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		TN	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NY	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		NJ	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		354643	9/8/2020 10:45 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1679029771 ( )		9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		SC	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NC	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		GA	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		FL	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		TN	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NY	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		NJ	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649726738	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1679029771	9/8/2020 10:45 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:45 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649726738 ( )		9/8/2020 10:45 AM
Details	Last Recertification Date	Update	Recertification	9/5/2019 4:21:26 PM	9/8/2020 10:45:18 AM	9/8/2020 10:45 AM
Contacts	Authorizing Official	Update	AO Change Request	Johnson, Paul Regional COO Prisma Health- Upstate 7704556240	Agnew, James Scott CEO Prisma Health Greenville Memorial 8644555286	10/1/2019 2:44 PM
Details	Last Recertification Date	Update	Recertification	8/30/2018 3:23:56 PM	9/5/2019 4:21:26 PM	9/5/2019 4:21 PM
Contacts	Primary Contact	Update	Change Request	carros, sam pharmacy manager Prisma Health Greenville Memorial Medical Campus 8645223821	carros, sam george Supply Chain and 340B Pharmacist Prisma Health GREENVILLE MEMORIAL HOSPITAL 8645223821	6/13/2019 7:55 AM
Contacts	Authorizing Official	Update	Change Request	Johnson, Paul Regional COO, Prisma Health- Upstate Greenville Memorial Hospital 8644556250	Johnson, Paul Regional COO Prisma Health- Upstate 7704556240	6/3/2019 6:39 AM
Details	Entity Name	Update	Change Request	GREENVILLE MEMORIAL HOSPITAL	Prisma Health GREENVILLE MEMORIAL HOSPITAL	6/3/2019 6:39 AM
Contacts	Authorizing Official	Update	Profile Change Request	Johnson, Paul President- GMMC Campus Greenville Memorial Hospital 8644556250	Johnson, Paul Regional COO, Prisma Health- Upstate Greenville Memorial Hospital 8644556250	4/11/2019 3:03 PM
Contacts	Signed By	Update	Profile Change Request	Johnson, Paul President- GMMC Campus Greenville Memorial Hospital 8644556250	Johnson, Paul Regional COO, Prisma Health- Upstate Greenville Memorial Hospital 8644556250	4/11/2019 3:03 PM
Contacts	Primary Contact	Update	Profile Change Request	carros, sam pharmacy manager Greenville Memorial Hospital 8645223821	carros, sam pharmacy manager Prisma Health Greenville Memorial Medical Campus 8645223821	4/9/2019 9:57 AM
Details	Last Recertification Date	Update	Recertification	11/13/2017 4:32:29 PM	8/30/2018 3:23:56 PM	8/30/2018 3:23 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1649726738	12/1/2017 4:31 PM
Medicaid Billing	Medicaid: Number	Update	Change Request	111717	354643	11/21/2017 6:37 PM
Details	Last Recertification Date	Update	Recertification	8/24/2016 12:00:00 AM	11/13/2017 4:32:29 PM	11/13/2017 4:32 PM
Contacts	Authorizing Official	Update		Johnson, Paul President- GMMC Campus 8644556250	Johnson, Paul President- GMMC Campus Greenville Memorial Hospital 8644556250	10/10/2017 7:03 PM
Contacts	Signed By	Update		Johnson, Paul President- GMMC Campus 8644556250	Johnson, Paul President- GMMC Campus Greenville Memorial Hospital 8644556250	10/10/2017 7:03 PM
Contacts	Primary Contact	Update		carros, sam pharmacy manager 8645223821	carros, sam pharmacy manager Greenville Memorial Hospital 8645223821	9/19/2017 5:08 PM
Contacts	Authorizing Official	Insert			Johnson, Paul President- GMMC Campus 8644556250	8/9/2017 2:22 PM
Contacts	Signed By	Insert			Johnson, Paul President- GMMC Campus 8644556250	8/9/2017 2:22 PM
Contacts	Primary Contact	Insert			carros, sam pharmacy manager 8645223821	7/5/2017 1:45 PM
Addresses	Main Address	Insert			65 international drive greenville, SC 29615	6/12/2017 2:26 PM
Addresses	Shipping Address	Insert			CCC-eastside 65 International Dr Greenville, SC 29615	6/12/2017 2:26 PM
Addresses	Shipping Address	Insert			GHS Pharmacy Consolidated Service Center 1071 Holland Rd Simpsonville, SC 29681	6/12/2017 2:26 PM
Medicaid Billing	Medicaid: Number	Update		354643	111717	1/13/2017 3:18 PM
Medicaid Billing	NPI: Number	Update		1699624900	1679029771	1/13/2017 3:18 PM
Details	Last Recertification Date	Update		8/17/2015 12:00:00 AM	8/24/2016 12:00:00 AM	8/24/2016 11:34 AM
Details	Last Recertification Date	Update		8/14/2014 12:00:00 AM	8/17/2015 12:00:00 AM	8/17/2015 3:18 PM
Details	Last Recertification Date	Update		8/30/2013 12:04:52 PM	8/14/2014 12:00:00 AM	8/14/2014 3:21 PM
Details	Last Recertification Date	Update			8/30/2013 12:04:52 PM	8/30/2013 12:04 PM
Details	340B ID	Update		IS-FF-DSH420078AA	DSH420078AA	6/11/2013 9:38 AM
Dates	Participating Approval Date	Update			6/11/2013 12:00:00 AM	6/11/2013 9:38 AM
Details	State	Update		Pending	Active	6/11/2013 9:38 AM
Dates	Start Date	Update			7/1/2013 12:00:00 AM	6/11/2013 9:38 AM
Details	340B ID	Update		Delete FF 5.9.12OUTPATIENT_ONLINE_REG	IS-FF-DSH420078AA	5/17/2013 1:06 PM
Details	State	Update		Rejected	Pending	5/17/2013 1:06 PM
Details	Comments Public	Insert			5/17/13 - Entity submitted supporting documents, reviewed registrations and forwarded to IS for approval. 5/9/13 - Delete, no supporting documents submitted.	5/17/2013 1:06 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	Delete FF 5.9.12OUTPATIENT_ONLINE_REG	5/9/2013 12:07 PM
Details	State	Update		Pending	Rejected	5/9/2013 12:07 PM
Details	Comments Public	Insert			5/9/13 - Delete, no supporting documents submitted.	5/9/2013 12:07 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/15/2013 5:06 PM
Medicaid Billing	Medicaid: Number	Insert			354643	4/15/2013 5:06 PM
Medicaid Billing	Medicaid: State	Insert			SC	4/15/2013 5:06 PM
Medicaid Billing	NPI: Number	Insert			1699624900	4/15/2013 5:06 PM
Details	Last Recertification Date	Insert				4/15/2013 5:06 PM
Details	Grant Number	Insert				4/15/2013 5:06 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	4/15/2013 5:06 PM
Details	Is Authorizing Official EHB Data	Insert				4/15/2013 5:06 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/15/2013 5:06 PM
Details	Medicare Provider Number	Insert			420078	4/15/2013 5:06 PM
Details	Entity Name	Insert			GREENVILLE MEMORIAL HOSPITAL	4/15/2013 5:06 PM
Details	Program Code	Insert			DSH	4/15/2013 5:06 PM
Details	Entity Subname	Insert			ccc-eastside	4/15/2013 5:06 PM
Dates	Participating Approval Date	Insert				4/15/2013 5:06 PM
Details	State	Insert			Pending	4/15/2013 5:06 PM
Dates	Registration Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 5:06 PM
Dates	Signed By Date	Insert			4/15/2013 12:00:00 AM	4/15/2013 5:06 PM
Dates	Start Date	Insert				4/15/2013 5:06 PM
Terminations	Termination Comments	Insert				4/15/2013 5:06 PM
Terminations	Termination Date	Insert				4/15/2013 5:06 PM
Terminations	Termination Effective Date	Insert				4/15/2013 5:06 PM
Terminations	Termination Reason	Insert				4/15/2013 5:06 PM