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LONG'S KILBOURNE ROAD PHARMACY
DSH420086 PRISMA HEALTH BAPTIST HOSPITAL
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Covered Entity Details
Entity Name
PRISMA HEALTH BAPTIST HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420086
Entity Address
1333 Taylor Street
COLUMBIA, SC 29202
Medicare Provider Number
420086
Participating Start Date
7/1/2006
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
LONG'S KILBOURNE ROAD PHARMACY
Pharmacy Address
D/B/A AVITA PHARMACY 1053
630 KILBOURNE RD
COLUMBIA, SC 29205-2827
Pharmacy Comments
Contract Details
Approval Date
3/1/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/9/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James M. Bridges, Acute Care Executive
(803) 296-5174
Contract Pharmacy Representative
Long's Drugs
Christi Epps, PharmD
(404) 270-9242
Signed By Date
1/14/2013
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