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PALMETTO INFUSION SERVICES LLC
DSH420004 MEDICAL UNIVERSITY HOSPITAL AUTHORITY
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Covered Entity Details
Entity Name
MEDICAL UNIVERSITY HOSPITAL AUTHORITY
Subdivision Name
MEDICAL UNIVERSITY HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH420004
Entity Address
169 ASHLEY AVENUE
CHARLESTON, SC 29425
Medicare Provider Number
420004
Participating Start Date
12/1/1992
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
PALMETTO INFUSION SERVICES LLC
Pharmacy Address
217 DOZIER BLVD
STE 102
FLORENCE, SC 29501
Pharmacy Comments
Contract Details
Approval Date
10/11/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thomas C Crawford, Chief Operating Officer
(843) 792-8775
Contract Pharmacy Representative
Palmetto Infusion
David Goodall, CEO
(800) 809-1265 Ext: 1006
Signed By Date
10/11/2021
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