Covered Entity Details

DSH420091A MUSC Health Florence Medical Center (Active) - information as of 5/27/2025 2:43:25 PM

Main Details

Name

MUSC Health Florence Medical Center

Subdivision Name

Operating Room - Ambulatory Surgery Center

Type

Disproportionate Share Hospital

Rural

340B ID

DSH420091A

Medicare Provider Number

420091

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

10/11/2019

Participating Start Date

1/1/2020

Participating Approval Date

11/24/2019

Last Recertification Date

8/19/2024

Contacts

Authorizing Official

Medical University Hospital Authority
Thomas C Crawford, Chief Operating Officer
(843) 792-8775

Primary Contact

MUSC Health
Sharelle Brown, Executive System Director Pharmacy Business and Finance
(248) 396-8085

Addresses

Street Address

1580 Freedom Blvd
3rd floor
Florence, SC 29505

Billing Address

MEDICAL UNIVERSITY HOSPITAL AUTHORITY
PO Box 31244
Salt Lake City, UT 84131

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	003162150A
NC	1073605879
SC		1184197683,1699248195

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
DSH420091A	Child	DSH	MUSC Health Florence Medical Center	Operating Room - Ambulatory Surgery Center	1580 Freedom Blvd	Florence	SC	Active
DSH420091B	Child	DSH	MUSC Health Florence Medical Center	MUSC HEALTH FLORENCE MEDICAL CENTER - Cedar Tower	121 E CEDAR ST	FLORENCE	SC	Terminated
DSH420091C	Child	DSH	MUSC Health Florence Medical Center	Wound Care - Wound Center	1580 Freedom Blvd	Florence	SC	Active
DSH420091D	Child	DSH	MUSC Health Florence Medical Center	Radiology - Diagnostic - Women's Center	1590 Freedom Blvd	Florence	SC	Active
DSH420091E	Child	DSH	MUSC Health Florence Medical Center	Speech Pathology - FLO - Speech Therapy - OP (FMC)	1925 Hoffmeyer Road	Florence	SC	Active
DSH420091F	Child	DSH	MUSC Health Florence Medical Center	Labor Room and Delivery Room - FLO - Labor & Delivery (FMC)	1590 Freedom Blvd	Florence	SC	Active
DSH420091G	Child	DSH	MUSC Health Florence Medical Center	Physical Therapy - FLO - Physical Therapy - OP (FMC)	1925 Hoffmeyer Road	Florence	SC	Active
DSH420091H	Child	DSH	MUSC Health Florence Medical Center	Occupational Therapy - FLO - Occupational Therapy - OP (FMC)	1925 Hoffmeyer Road	Florence	SC	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	Last Recertification Date	Update	Recertification	8/24/2023 4:55:14 PM	8/19/2024 11:45:33 AM	8/19/2024 11:45 AM
Contacts	Primary Contact	Update	Group Change Request	Kushner, Gail M Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 8439852371	Brown, Sharelle Executive System Director Pharmacy Business and Finance MUSC Health 2483968085	8/19/2024 11:19 AM
Addresses	Billing Address	Insert	Group Change Request		MEDICAL UNIVERSITY HOSPITAL AUTHORITY PO Box 31244 Salt Lake City, UT 84131	3/25/2024 1:17 PM
Addresses	Main Address	Update	Change Request	1580 Freedom Blvd Florence, SC 29505	1580 Freedom Blvd 3rd floor Florence, SC 29505	1/9/2024 9:41 AM
Contacts	Authorizing Official	Update	Change Request	Goodlett, Lisa Chief Financial Officer Medical University Hospital Authority 8437924775	Crawford, Thomas C Chief Operating Officer Medical University Hospital Authority 8437928775	11/27/2023 4:24 PM
Details	Last Recertification Date	Update	Recertification	8/28/2022 8:56:38 AM	8/24/2023 4:55:14 PM	8/24/2023 4:55 PM
Contacts	Primary Contact	Update	Profile Change Request	Kushner, Gail Marcia Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 8439852371	Kushner, Gail M Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 8439852371	7/3/2023 7:46 AM
Contacts	Primary Contact	Update	Profile Change Request	Kushner, Gail Marcia Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 2038584254	Kushner, Gail Marcia Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 8439852371	4/1/2023 12:14 PM
Contacts	Primary Contact	Update	PC Change Request	Knudsen, Alan 340B Manager Medical University Hospital Authority 8437925691	Kushner, Gail Marcia Director, 340B MEDICAL UNIVERSITY HOSPITAL AUTHORITY 2038584254	9/14/2022 1:42 PM
Details	Last Recertification Date	Update	Recertification	8/30/2021 11:07:53 AM	8/28/2022 8:56:38 AM	8/28/2022 8:56 AM
Details	Last Recertification Date	Update	Recertification	9/11/2020 12:47:30 PM	8/30/2021 11:07:53 AM	8/30/2021 11:07 AM
Contacts	Primary Contact	Update	Change Request	Mills, Jason Pharmacy Manager Medical University Hospital Authority 8437927354	Knudsen, Alan 340B Manager Medical University Hospital Authority 8437925691	4/23/2021 2:45 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 12:47 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		003162150A	9/11/2020 12:47 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		GA	9/11/2020 12:47 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/11/2020 12:47 PM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1073605879	9/11/2020 12:47 PM
Medicaid Billing	Medicaid: State	Insert	Recertification		NC	9/11/2020 12:47 PM
Medicaid Billing	NPI: State	Update	Recertification		SC	9/11/2020 12:47 PM
Medicaid Billing	NPI: State	Update	Recertification		SC	9/11/2020 12:47 PM
Details	Last Recertification Date	Update	Recertification		9/11/2020 12:47:30 PM	9/11/2020 12:47 PM
Details	State	Update		Approved	Active	1/1/2020 12:04 AM
Details	Entity Name	Update	Change Request	CAROLINAS HOSPITAL SYSTEM	MUSC Health Florence Medical Center	12/13/2019 3:47 PM
Contacts	Signed By	Insert	New Registration		Goodlett, Lisa Chief Financial Officer Medical University Hospital Authority 8437924775	11/24/2019 7:24 PM
Details	340B ID	Update	New Registration		DSH420091A	11/24/2019 7:24 PM
Details	Entity Subname	Update	New Registration	Operating Room	Operating Room - Ambulatory Surgery Center	11/24/2019 7:24 PM
Dates	Participating Approval Date	Update	New Registration		11/24/2019 7:24:10 PM	11/24/2019 7:24 PM
Details	State	Update	New Registration	Pending	Approved	11/24/2019 7:24 PM
Dates	Signed By Date	Update	New Registration		10/14/2019 12:11:36 PM	11/24/2019 7:24 PM
Dates	Start Date	Update	New Registration		1/1/2020 12:00:00 AM	11/24/2019 7:24 PM
Addresses	Main Address	Insert	New Registration		1580 Freedom Blvd Florence, SC 29505	10/11/2019 3:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1184197683	10/11/2019 3:08 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1699248195	10/11/2019 3:08 PM
Contacts	Primary Contact	Insert	New Registration		Mills, Jason Pharmacy Manager Medical University Hospital Authority 8437927354	10/11/2019 3:08 PM
Contacts	Authorizing Official	Insert	New Registration		Goodlett, Lisa Chief Financial Officer Medical University Hospital Authority 8437924775	10/11/2019 3:08 PM
Details	Last Recertification Date	Insert	New Registration			10/11/2019 3:08 PM
Details	Grant Number	Insert	New Registration			10/11/2019 3:08 PM
Details	340B ID	Insert	New Registration			10/11/2019 3:08 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			10/11/2019 3:08 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			10/11/2019 3:08 PM
Details	Medicare Provider Number	Insert	New Registration		420091	10/11/2019 3:08 PM
Details	Entity Name	Insert	New Registration		CAROLINAS HOSPITAL SYSTEM	10/11/2019 3:08 PM
Details	Program Code	Insert	New Registration		DSH	10/11/2019 3:08 PM
Details	Entity Subname	Insert	New Registration		Operating Room	10/11/2019 3:08 PM
Dates	Participating Approval Date	Insert	New Registration			10/11/2019 3:08 PM
Details	State	Insert	New Registration		Pending	10/11/2019 3:08 PM
Dates	Registration Date	Insert	New Registration		10/11/2019 3:08:11 PM	10/11/2019 3:08 PM
Dates	Signed By Date	Insert	New Registration			10/11/2019 3:08 PM
Dates	Start Date	Insert	New Registration			10/11/2019 3:08 PM
Terminations	Termination Comments	Insert	New Registration			10/11/2019 3:08 PM
Terminations	Termination Date	Insert	New Registration			10/11/2019 3:08 PM
Terminations	Termination Effective Date	Insert	New Registration			10/11/2019 3:08 PM
Terminations	Termination Reason	Insert	New Registration			10/11/2019 3:08 PM