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DSH420078Z GREENVILLE MEMORIAL HOSPITAL (Terminated)
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Main Details
Name
GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
ccc grove
Type
Disproportionate Share Hospital
Rural
No
340B ID
DSH420078Z
Medicare Provider Number
420078
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
4/15/2013
Participating Start Date
7/1/2013
Participating Approval Date
6/11/2013
Last Recertification Date
11/13/2017
Termination Date
Termination Reason
1/1/2018
Business decision by the Covered Entity
Contacts
Authorizing Official
Prisma Health Greenville Memorial
James Scott Agnew, CEO
(864) 455-5286
Primary Contact
Prisma Health Greenville Memorial Medical Campus
sam carros, pharmacy manager
(864) 522-3821
Addresses
Street Address
3 butternut drive , suite b
greenville, SC 29605
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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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
May 2025
May 2025
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