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SOUTH CAROLINA CVS PHARMACY, L.L.C.
DSH420071 SELF REGIONAL HEALTHCARE
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Covered Entity Details
Entity Name
SELF REGIONAL HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420071
Entity Address
1325 SPRING STREET
GREENWOOD, SC 29646
Medicare Provider Number
420071
Participating Start Date
1/1/2007
Last Recertification Date
8/24/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
SOUTH CAROLINA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 04173
1302 HWY 72-221 EAST
GREENWOOD, SC 29649
Pharmacy Comments
Contract Details
Approval Date
4/23/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
CAMIE PATTERSON, VICE PRESIDENT & CFO
(864) 725-4255
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
4/23/2014
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