Covered Entity Details

DSH420020D GEORGETOWN MEMORIAL HOSPITAL (Terminated) - information as of 6/18/2025 1:14:08 AM

Main Details

Name

GEORGETOWN MEMORIAL HOSPITAL

Subdivision Name

GEORGETOWN ENDOSCOPY CENTER

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH420020D

Medicare Provider Number

420020

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/2/2015

Participating Start Date

7/1/2015

Participating Approval Date

6/10/2015

Last Recertification Date

11/21/2017

Termination Date
Termination Reason

7/1/2018
Outpatient facility moved within the 4 walls of the parent hospital

Contacts

Authorizing Official

Georgetown Memorial Hospital
Gayle Lynn Resetar, COO
(843) 527-7100

Primary Contact

Georgetown Memorial Hospital
AMBROSE HOLLIDAY, DIRECTOR OF OUTPATIENT PHARMACY SERVICES
(843) 527-7497

Addresses

Street Address

2361 N. FRASER STREET
GEORGETOWN, SC 29440

Billing Address

GEORGETOWN ENDOSCOPY CENTER
606 BLACK RIVER ROAD
GEORGETOWN, SC 29440

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
SC	343274
		1982604021

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
DSH420020A	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	Tidelands Health Pain Management Services at Georgetown	219 Church St	GEORGETOWN	SC	Terminated
DSH420020B	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	Tidelands Health Francis B. Ford Cancer Treatment Center	2405 N FRASER ST	GEORGETOWN	SC	Terminated
DSH420020C	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	Tidelands Health Cancer Care Network at Murrells Inlet	4181 HIGHWAY 17	MURRELLS INLET	SC	Terminated
DSH420020D	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	GEORGETOWN ENDOSCOPY CENTER	2361 N. FRASER STREET	GEORGETOWN	SC	Terminated
DSH420020E	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	TIDELANDS HEALTH WOUND CARE AND INFUSION CENTER AT MURRELLS INLET/TIDELANDS HEALTH ECHO/VASCULAR LAB AT MURRELLS INLET	4367 RIVERWOOD DR UNIT 140	MURRELLS INLET	SC	Terminated
DSH420020F	Child	DSH	GEORGETOWN MEMORIAL HOSPITAL	Tidelands Health Cancer Care Network at Myrtle Beach	1220 21st Ave N	Myrtle Beach	SC	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	7/1/2018 12:00 AM
Dates	Last Date That 340B Drugs Purchased	Update	Termination Request		2/12/2018 12:00:00 AM	4/25/2018 1:01 PM
Details	State	Update	Termination Request	Active	To Be Terminated	4/25/2018 1:01 PM
Terminations	Termination Date	Update	Termination Request		7/1/2018 12:00:00 AM	4/25/2018 1:01 PM
Terminations	Termination Effective Date	Update	Termination Request		3/22/2018 12:00:00 AM	4/25/2018 1:01 PM
Terminations	Termination Reason	Update	Termination Request		Outpatient facility moved within the 4 walls of the parent hospital	4/25/2018 1:01 PM
Contacts	Authorizing Official	Insert	Change Request		Resetar, Gayle Lynn COO Georgetown Memorial Hospital 8435277100	11/28/2017 9:00 AM
Contacts	Signed By	Update	Profile Change Request	RESETAR, GAYLE COO Tidelands Georgetown Memorial Hospital 8435277100	RESETAR, GAYLE Lynn COO Tidelands Georgetown Memorial Hospital 8435277100	11/28/2017 8:21 AM
Details	Last Recertification Date	Update	Recertification	8/22/2016 12:00:00 AM	11/21/2017 11:57:51 AM	11/21/2017 11:57 AM
Contacts	Signed By	Update		RESETAR, GAYLE COO 8435277100	RESETAR, GAYLE COO Tidelands Georgetown Memorial Hospital 8435277100	11/21/2017 11:54 AM
Contacts	Primary Contact	Update		HOLLIDAY, AMBROSE DIRECTOR OF OUTPATIENT PHARMACY SERVICES 8435277497	HOLLIDAY, AMBROSE DIRECTOR OF OUTPATIENT PHARMACY SERVICES Georgetown Memorial Hospital 8435277497	11/9/2017 12:45 PM
Contacts	Signed By	Insert			RESETAR, GAYLE COO 8435277100	4/3/2017 1:30 PM
Addresses	Main Address	Insert			2361 N. FRASER STREET GEORGETOWN, SC 29440	8/22/2016 12:31 PM
Contacts	Primary Contact	Insert			HOLLIDAY, AMBROSE DIRECTOR OF OUTPATIENT PHARMACY SERVICES 8435277497	8/22/2016 12:31 PM
Details	Last Recertification Date	Update		8/5/2015 12:00:00 AM	8/22/2016 12:00:00 AM	8/22/2016 12:31 PM
Addresses	Billing Address	Insert			GEORGETOWN ENDOSCOPY CENTER 606 BLACK RIVER ROAD GEORGETOWN, SC 29440	4/12/2016 3:49 PM
Details	Last Recertification Date	Update			8/5/2015 12:00:00 AM	8/5/2015 10:11 AM
Dates	Participating Approval Date	Update			6/10/2015 12:00:00 AM	6/10/2015 10:29 AM
Details	State	Update		Pending	Active	6/10/2015 10:29 AM
Dates	Start Date	Update			7/1/2015 12:00:00 AM	6/10/2015 10:29 AM
Details	340B ID	Update		DEL_05122015_50469	DSH420020D	5/20/2015 9:51 AM
Details	State	Update		Rejected	Pending	5/20/2015 9:51 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_50469	DEL_05122015_50469	5/12/2015 1:46 PM
Details	State	Update		Pending	Rejected	5/12/2015 1:46 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_50469	4/2/2015 2:55 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/2/2015 2:55 PM
Medicaid Billing	Medicaid: Number	Insert			343274	4/2/2015 2:55 PM
Medicaid Billing	Medicaid: State	Insert			SC	4/2/2015 2:55 PM
Medicaid Billing	NPI: Number	Insert			1982604021	4/2/2015 2:55 PM
Details	Last Recertification Date	Insert				4/2/2015 2:55 PM
Details	Grant Number	Insert				4/2/2015 2:55 PM
Details	340B ID	Insert				4/2/2015 2:55 PM
Details	Is Authorizing Official EHB Data	Insert				4/2/2015 2:55 PM
Dates	Last Date That 340B Drugs Purchased	Insert				4/2/2015 2:55 PM
Details	Medicare Provider Number	Insert			420020	4/2/2015 2:55 PM
Details	Entity Name	Insert			GEORGETOWN MEMORIAL HOSPITAL	4/2/2015 2:55 PM
Details	Program Code	Insert			DSH	4/2/2015 2:55 PM
Details	Entity Subname	Insert			GEORGETOWN ENDOSCOPY CENTER	4/2/2015 2:55 PM
Dates	Participating Approval Date	Insert				4/2/2015 2:55 PM
Details	State	Insert			Pending	4/2/2015 2:55 PM
Dates	Registration Date	Insert			4/2/2015 12:00:00 AM	4/2/2015 2:55 PM
Dates	Signed By Date	Insert			4/2/2015 12:00:00 AM	4/2/2015 2:55 PM
Dates	Start Date	Insert				4/2/2015 2:55 PM
Terminations	Termination Comments	Insert				4/2/2015 2:55 PM
Terminations	Termination Date	Insert				4/2/2015 2:55 PM
Terminations	Termination Effective Date	Insert				4/2/2015 2:55 PM
Terminations	Termination Reason	Insert				4/2/2015 2:55 PM