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WAL-MART PHARMACY 10-0616
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
WAL-MART PHARMACY 10-0616
Pharmacy Address
2795 NORTH RD
ORANGEBURG, SC 29118
Pharmacy Comments
Contract Details
Approval Date
4/6/2023
Contract Begin Date
4/18/2023
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
Thomas C Crawford, Chief Operating Officer
(843) 792-8775
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
4/6/2023
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