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WAL-MART PHARMACY 10-1829
DSH420055 MUSC HEALTH MARION MEDICAL CENTER
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Covered Entity Details
Entity Name
MUSC HEALTH MARION MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420055
Entity Address
2829 EAST HWY 76
MULLINS, SC 29574
Medicare Provider Number
420055
Participating Start Date
7/1/2020
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1829
Pharmacy Address
305 COMMERCE DRIVE
MARION, SC 29571
Pharmacy Comments
Contract Details
Approval Date
7/13/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/3/2024
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
7/13/2020
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