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IVA DRUG STORE, INC.
CAH421301-03 ABBEVILLE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ABBEVILLE COUNTY MEMORIAL HOSPITAL
Subdivision Name
ABBEVILLE COUNTY MEMORIAL HOSPITAL-Due West Family Medicine Clinic
Type
Critical Access Hospital
340B ID
CAH421301-03
Entity Address
6 COLLEGE ST #638
DUE WEST, SC 29639-9554
Medicare Provider Number
421301
Outpatient Facility Provider Number
423453
Participating Start Date
7/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
IVA DRUG STORE, INC.
Pharmacy Address
720 E FRONT ST
P.O. BOX 26
IVA, SC 29655-9089
Pharmacy Comments
Contract Details
Approval Date
10/7/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
TIMOTHY WREN, CFO
(864) 366-3310
Contract Pharmacy Representative
CORPORATION
Lance Boles, Owner/Pharmacist
(706) 376-5801
Signed By Date
10/7/2019
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