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WAL-MART PHARMACY 10-2703
DSH420091 MUSC Health Florence Medical Center
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Covered Entity Details
Entity Name
MUSC Health Florence Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420091
Entity Address
805 PAMPLICO HIGHWAY
FLORENCE, SC 29505
Medicare Provider Number
420091
Participating Start Date
1/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2703
Pharmacy Address
2014 SO. IRBY STREET
FLORENCE, SC 29505
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Goodlett, Chief Financial Officer
(843) 792-4775
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/15/2020
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