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WAL-MART PHARMACY 10-1130
DSH420078 Prisma Health GREENVILLE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
Prisma Health GREENVILLE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420078
Entity Address
701 GROVE ROAD
GREENVILLE, SC 29605
Medicare Provider Number
420078
Participating Start Date
4/1/1999
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1130
Pharmacy Address
922 E MAIN STREET
LAURENS, SC 29360
Pharmacy Comments
Contract Details
Approval Date
4/15/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Barrett Ludley, CFO
(864) 455-6405
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2022
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